Columbia  ®ntber^tt|^of)  ' 
in  tfje  Citp  of  iBteto  gorfe 

College  of  $fjpgtrians  anb  i-burgeons 


Reference  Htbrarp 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/caseteachinginsuOOburr 


CASE  TEACHING 


IN 


SURGERY 


BY 


HERBERT  L.  BURRELL,  M.D. 

PROFESSOR    OF    CLINICAL    SURGERY,    HARVARD    UNIVERSITY 


AND 


JOHN  BAPST  BLAKE,  M.D. 

INSTRUCTOR    IN    SURGERY,     HARVARD     UNIVERSITY 


PHILADELPHIA 

P.   BLAKISTON'S  SON  &   CO. 

IOI2    WALNUT    STREET 
1904 


iztot 

Copyright,   1004,  by  P.  Blakiston's  Son  &  Co. 


PRESS   OF 

WM,   F.   FELL  COMPANY 

PHILADELPHIA 


PREFACE. 


The  following  histories  of  cases  have  been  collected  and  printed 
to  facilitate  the  case  method  of  teaching  in  surgery  at  the  Harvard 
Medical  School.  Dr.  Blake  has  for  three  years  found  that  in  the 
latter  part  of  the  last  year  in  the  course  in  surgical  instruction  this 
method  of  teaching  has  served  to  assemble  the  more  or  less  disjointed 
knowledge  that  the  students  have  acquired  in  the  various  fundamental 
and  applied  courses. 

The  writers  believe  that  the  case  method  needs  wider  recognition 
in  the  art  of  teaching  surgery.  There  are  many  and  varied  advantages 
in  the  method.  It  gives  the  instructor  a  boundless  amount  of  mate- 
rial; he  may  utilize  all  his  histories  in  private  and  hospital  practice; 
he  may  use  the  histories  of  cases  that  have  been  under  the  care  of 
other  surgeons;  he  may  present  cases  that  illustrate  the  variations 
in  the  common  forms  of  disease;  he  may  collect  rare  and  unique 
examples  of  disease;  he  may  present  histories  that  are  complete  or 
incomplete;  and  he  may,  if  he  chooses,  omit  important  details  from 
the  history  of  a  case. 

The  most  important  advantage  that  the  method  presents  is  its 
adaptability  and  elasticity  to  the  needs  of  the  instructor.  No  one 
can  make  a  success  of  this  method  unless  he  adopts  his  own  individual 
way  of  conducting  the  exercises.  The  instructor  should  guide  and 
suggest,  but  the  student  should  talk  and  discuss  the  case.  In  other 
words,  the  student  should  be  active  and  productive,  rather  than 
passive  and  receptive.  Each  instructor,  after  trying  the  method  will 
adopt  a  plan  of  his  own  and,  after  all,  this  is  the  fundamental  prin- 
ciple of  good  teaching.  A  very  definite  advantage  is  that  the  instructor 
may  develop  the  instruction  along  whatever  lines  he  may  elect; 
for  example,  the  discussion  of  a  case  may  bear  upon  etiology,  symp- 
tomatology, diagnosis,  differential  diagnosis,  prognosis,  or  treatment. 
A  very  definite  advantage  to  the  instructor  is  that,  if  the  students  are 
allowed  to  do  the  questioning,  they  will  quickly  demonstrate  their 
need  of  instruction,  whether  it  be  in  diagnosis,  prognosis,  or  treatment. 

In  the  explanatory  note  Dr.  Blake  describes  his  personal  method 
of  using  case  teaching  in  surgery.     It  is  hoped  to  make  the  cases 


more  interesting  by  withholding  the  diagnosis.  The  key  will  be 
mailed  to  instructors  who  wish  it. 

It  is  necessary  to  emphasize  the  fact  that  the  case  method  is  not 
intended  as  a  substitute  for  the  accepted  methods  of  surgical  teaching. 
These  are  the  lecture,  the  clinic,  the  quiz,  and  the  small  bedside  sec- 
tion. To  them,  however,  the  case  method  may  be  made  to  act  as  a 
supplement,  filling  gaps  which  may  exist  between  them,  and  develop- 
ing needs  of  students  which  would  otherwise  have  escaped  observa- 
tion. 

We  desire  to  acknowledge  the  valuable  assistance  of  Dr.  W.  C. 
Peters,  who  has  with  much  care  selected  a  number  of  the  following 
cases. 


EXPLANATORY  NOTE. 

A  method  of  conducting  the  case  teaching  exercises  which  has 
proved  satisfactory,  is  as  follows: 

The  instructor  reads  the  selected  case  to  the  assembled  class 
legitimate  questions  concerning  the  text  are  answered,  and  missing 
information  that  may  properly  be  supplied  is  given,  if  requested  by 
the  students.  Five  to  ten  minutes  are  allowed  for  silent  consideration 
of  the  case,  and  the  discussion  is  then  commenced.  One  of  the  class 
is  asked  to  summarize  the  case;  for  example:  "This  is  an  acute 
abdominal  attack  in  an  old  man,"  "a  chronic  gastric  condition  with 
an  exacerbation,  in  a  middle-aged  woman,"  etc.  This  is,  of  course, 
merely  pointing  the  direction  in  which  the  diagnosis  lies;  yet  it  serves 
as  a  point  of  departure.  Possibilities  are  considered  and  ruled  out 
as  rapidly  as  may  be,  the  instructor  taking  care  that  the  student  does 
the  talking,  makes  the  suggestions,  and  raises  the  objections.  When 
a  positive  diagnosis  is  reached,  or  if  individuals  differ  in  diagnoses, 
the  instructor  may  proceed  to  treatment,  which  should  be  discussed 
in  its  widest  aspect  and  its  minutest  details.  It  is  well  to  ask  the 
students  to  consider  the  case  as  if  it  were  not  in  a  hospital,  but  in 
circumstances  where  the  doctor  must  give  accurate  directions  and 
personal  supervision  to  every  detail  of  treatment.  If  an  operation 
is  indicated,  the  time,  the  preparation,  the  anesthetic,  the  stimulation, 
the  immediate  after-treatment,  as  well  as  each  step  of  the  operation 
itself,  must  be  most  thoroughly  covered. 

The  prognosis  is  to  be  approached  from  the  practical  standpoint 
of  the  man  who  wants  to  know  when  he  may  return  to  work. 
The  possibility  of  late  sequelae,  of  recurrent  attacks,  of  contagion, 
etc.,  are  also  to  be  viewed  from  the  essentially  practical  point  of  view. 

Last  of  all,  the  correct  diagnosis  and  a  narrative  of  operation, 
results,  convalescence,  or  the  full  detail  of  the  autopsy  in  fatal  cases 
is  announced  by  the  instructor.  In  the  light  of  the  diagnosis,  the 
case  may  then  be  advantageously  and  briefly  reviewed, — important 
points  emphasized,  symptoms  which  were  puzzling  or  apparently 
unimportant  interpreted,  and  the  case  summarized  again  in  the 
manner  best  fitted  to  impress  its  salient  points  upon  the  students' 
attention. 

5 


If  the  exercise  is  of  two  hours'  duration,  it  is  sometimes  well  worth 
while  to  follow  the  first  by  a  second  case  illustrating  another  type 
or  example  of  the  same  disease.  This  is  particularly  to  be  desired 
when  the  cases  of  the  same  disease  differ  essentially  in  treatment 
and  prognosis.  The  writers  believe  these  cases  should  not  be  used 
to  simply  establish  a  diagnosis.  For  purposes  of  instruction,  the 
diagnosis  is  the  least  valuable  factor.  The  points  of  interest  in 
these  cases  should  be  used  as  pegs  upcn  which  to  hang  useful  in- 
formation. 


LIST  OF  ABBREVIATIONS. 

For  the  sake  of  brevity,  the  following  abbreviations  are  frequently 
used: 

Gen., General.  P., Pulse. 

Abd., Abdomen.  SI., Slight. 

Ant., Anterior.  Lt., Left. 

Post., Posterior.  Rt., Right. 

Fam.  Hist.,  . .  Family  History.  Neg., Negative. 

Prev.  Hist.,  .  .Previous  History.  Ur., Urine. 

Pres.  III., Present  Illness.  Resp., Respiration. 

Phys.  Exam.,  .Physical   Examina-  M., Male. 

tion.  F., Female. 

H.  &  L., Heart  and  Lungs.  Mod., Moderate. 

W.  D.  &  N.,  .Well  developed  and  Exam., Examination. 

nourished.  Tend., Tenderness. 

T., Temperature.  Mos., Months. 

Nor., Normal.  Yrs., Years. 


Figures  immediately  following  the  patient's  name  indicate  his  age. 


CASE  i. 

Male;  47;  married;  carpenter. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Negative. 

Pres.  III. — While  at  work  this  afternoon  a  piece  of  timber  flew 
from  a  circular  saw  and  struck  patient  in  abdomen.  Felt  faint  and 
vomited,  but  soon  felt  better,  walked  around  and  was  taken  home  in 
a  carriage.  Pain  and  nausea  returned.  Was  given  morphia  by 
physician  and  sent  to  hospital  four  hours  after  accident. 

Phys.  Exam. — Well  developed  and  nourished.  Temperature, 
10 1°;  pulse  100,  strong.  Looks  sick;  drowsy,  but  easily  aroused. 
Abdominal  wall  very  rigid,  but  not  distended.  Slightly  pale.  Gen- 
eral abdominal  tenderness,  most  marked  in  left  iliac  fossa,  where 
there  is  a  slight  superficial  contusion.  Dullness  over  pubes  at  both 
sides  extending  into  left  iliac  region.  Four  ounces  of  apparently 
normal  urine  drawn  by  catheter.  No  leucocytosis.  Bowels  moved 
slightly  after  enema.     Nothing  abnormal  in  stool. 


to 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


ii 


CASE  2. 

Male;   53;  married;  engineer. 

Transferred  from  Medical  Side. 

Fam.  Hist. — Father  died  of  alcohol;  mother  died  of  milk  leg; 
sister  died  in  child-bed. 

Prev.  Hist. — Malaria  in  1886,  rheumatic  fever  in  1876;  frequent 
rheumatic  attacks  since,  particularly  in  1885.  No  venereal.  At 
times  alcohol  to  excess. 

Pres.  III.  (August  5th). — For  eight  years  trouble  with  heart, 
dyspnea  and  precordial  pain.  Sent  to  Soldiers'  Home  for  seven 
months  and  returned  to  it  twice  again.  Has  worked  but  little. 
Some  cough,  no  blood.  Headache  with  vertigo  at  times.  Legs 
swollen  at  times  for  ten  years.    Micturition,  two  to  five  times  at  night. 

Phys.  Exam. — Pupils,  equal  and  react.  Pulse  regular,  small, 
poor  volume  and  tension,  no.  Temperature,  99. 50.  Heart,  much 
enlarged  to  right  and  left;  double  murmur  at  apex;  systolic  heard 
also  at  base.  Lungs,  dullness  and  diminished  resonance,  fine  and 
medium  moist  rales  below  fifth  rib,  sides,  and  back.  Abdomen, 
negative.  Urine,  N.  1023,  acid;  slight  trace  albumen;  some  brown 
granular  casts;  many  hyaline  and  fine  granular  casts,  some  with 
blood  and  leucocytes  adherent.  Slight  amount  of  abnormal  blood; 
many  small  round  cells;  some  squamous  and  neck  of  bladder  cells. 
Was  given  digitalis  and  potassium  acetate. 

August  20th:  Vomiting;  no  other  abdominal  symptoms.  Digitalis 
stopped. 

August  2 2d:  Absence  of  fremitus  and  respiration  in  lower  right 
back;  beginning  abdominal  tenderness  and  pain,  becoming  severe. 
Vomiting. 

August  23d:    Tympanites  with  tenderness,  retching,  and  nausea. 

August  24th:  General  moderate  distention,  with  universal  spasm; 
pulse  and  temperature  rising.  Attacks  of  sharp  abdominal  pain, 
which  disappear  and  recur.     Constipation.     No  leucocytosis. 


12 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


13 


CASE  3. 


Female;    24;   married;   housework. 

Fam.  Hist. — Negative. 

Preu.  Hist. — Negative. 

Pres.  III. — Patient  states  that  five  days  ago  she  stepped  on  a  rusty 
nail.  That  evening  had  chilly  sensation  and  malaise.  Distinct 
chill  every  evening  since.  Vomited  last  night.  Foot  almost  im- 
mediately became  reddened  and  tender.  Poulticed.  Doctor  told 
her  last  night  that  her  temperature  was  1060. 

Phys.  Exam. — Well  developed  and  nourished;  stout.  Tem- 
perature, 98. 40;  pulse  80,  good  volume  and  tension.  Thorax  and 
abdomen  negative,  save  that  edge  of  spleen  and  fiver  can  be  palpated. 
Right  foot  not  swollen  nor  tender,  no  redness  or  pain.  Small  recent 
scar.     No  lymphangitis.     White  count,  12,000. 


14 


Diagnosis  ?  Prognosis  ?  .    Treatment  ? 


15 


CASE  4. 

Female;   51;   married;   housework. 

Fam.  Hist. — Negative. 

Prev.  Hist. — For  more  than  one  year  patient  has  had  urinary 
symptoms;  has  passed  blood  at  times. 

Pres.  III. — At  4  a.m.  yesterday  patient  was  seized  with  severe 
abdominal  pain,  not  localized.  Vomited  greenish  fluid  several 
times.  Grew  worse  without  remission  of  symptoms.  Had  been 
working  and  feeling  as  well  as  usual  up  to  yesterday.  Constipated 
for  past  two  days. 

Phys.  Exam. — W.  D.  &  N.  Obese.  Mentally  dull.  Patient's 
history  contradictory.  Does  not  look  extremely  sick.  Pupils  small 
and  equal,  conjunctiva  not  yellow.  Tongue  coated.  Vomiting. 
Pulse  rapid,  poor  quality.  Heart  and  lungs  not  examined.  Ab- 
domen considerably  distended.  Moderate  general  tenderness. 
Considerable  general  spasm.  No  flatness.  No  tumor  felt.  Vaginal 
examination  shows  cervix  high,  just  in  reach  of  fingers.  Negative 
except  for  bloody  discharge.     No  leucocytosis. 

High  enema,  poor  result.  Several  unsuccessful  attempts  to  cathe- 
terize  made  by  nurse.  House  officer  found  greenish  ring  around 
meatus,  and  with  catheter  drew  a  few  ounces  of  dark,  bloody,  foul- 
smelling  fluid. 

Urine  dark,  1015.  Alk.  \%  alb.  Large  amount  of  sediment. 
Normal  blood.     Few  large  round  cells  and  squamous  epithelium. 


16 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


17 


CASE  J. 

Male;  30;   married;  stableman. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Negative. 

Pres.  III. — Friend  states  that  four  days  ago  patient  fell  from 
bicycle,  injuring  head.  Wounds  dressed  by  physician.  Patient 
normal  until  2  a.m.  to-day,  when  sudden  delirium,  requiring  restraint, 
developed. 

Phys.  Exam. — Unconscious.  Pupils  equal  and  react.  Diver- 
gent strabismus;  right  eye  most  affected.  Pulse  60,  good  volume, 
high  tension;  temperature,  990.  Respiration,  Cheyne-Stokes. 
Whole  right  face  moves  less  than  left.  Responds  to  supra-orbital 
pressure  by  irregular  movements.  Heart,  lungs,  and  abdomen 
negative.  Urine  normal.  Right  arm  moves  less  than  left.  Re- 
flexes present.  Babinsky  on  both  sides.  Leucocytosis,  11,000. 
Slight  general  muscular  spasm. 

Head. — Oval  depression,  size  of  five-cent  piece,  \  inch  deep,  in 
median  line,  upper  occipital  region.  Two  recent  wounds,  one  inch 
above  right  eyebrow,  sutured.  No  bleeding  from  ears  or  nose.  Ear 
drums  normal. 


iS 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


19 


CASE  6. 

Female;    25;    single;    waitress. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Always  well  and  strong. 

Pres.  III. — Two  days  ago  sudden  pain  in  right  hypochondrium, 
steady,  sharp  and  shooting  into  right  iliac  region.  Nausea  and 
vomiting.  No  chills.  Pain  continued  during  night;  morphia  given 
next  day.  Yesterday  symptoms  recurred.  This  morning,  pain 
localized  in  right  iliac;  vomiting  incessant,  no  diarrhea.  Came  to 
hospital  in  ambulance.     Leucocytosis,  10,600. 

Phys.  Exam. — F.  D.  &  N.  Heart  and  lungs  negative.  Urine 
negative.  Temperature,  ioo°;  pulse,  80.  Abdomen  somewhat 
distended,  especially  below  umbilicus,  more  on  left  than  right. 
Somewhat  rigid.  Tense  in  lower  left  quadrant.  Dullness  below 
umbilicus.  A  well-marked  resistance,  but  no  definite  tumor  made 
out  in  left  lower  quadrant. 

Vaginal  Exam. — Cervix  short,  smooth,  normal  density;  body  of 
uterus  not  felt.  Tenderness  to  left,  and  soft  smooth  mass  filling 
posterior  cul-de-sac.     No  vaginal  nor  urethral  discharge. 


20 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


CASE  7. 

Female;   22;   single;   factory  girl. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Negative. 

Pres.  III. — For  four  months  gradual  weakness,  anorexia,  night- 
sweats,  cough,  fever,  loss  of  flesh,  pain  in  chest.  Three  days  ago 
chill,  fever,  pain  in  right  chest  and  increasing  fullness. 

Phys.  Exam. — Respiration,  35;  pulse,  126;  temperature,  102. 50. 
Pale.  Heart  and  lower  abdomen  negative.  Liver  enlarged  (?). 
Entire  right  chest  dull.  Respiratory  sounds  diminished  in  upper 
part.     Respiration  and  fremitus  absent  below. 

Pulse  and  temperature  gradually  diminished,  and  a  tumor  appeared 
in  the  right  hypochondrium  which  was  tender,  dull  on  percussion 
and  not  distinctly  fluctuating.  Aspiration  of  chest  in  right  axillary 
line  revealed  a  serous  liquid,  slightly  hemorrhagic.  The  area  of 
dullness  increased.  One  week  later  tapped  again;  nothing  obtained. 
Leucocytes,  13  800.  Hemoglobin,  50%.  Slight  constipation.  Tem- 
perature and  pulse  continue  to  oscillate  moderately.  Patient  looks 
very  sick. 


22 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


23 


CASE  8. 

Male;    4^  years. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Pneumonia  two  years  ago.     Diphtheria  one  year  ago. 

Pres.  III. — Three  days  ago  developed  headache  and  began  to  vomit. 
Has  vomited  all  food  since.  General  abdominal  pain.  Feverish. 
No  chills  or  convulsions. 

Phys.  Exam. — Well  developed  and  poorly  nourished.  General 
condition  very  poor.  Temperature,  104.80;  pulse,  155.  Respira- 
tion, 40.  Heart  negative.  Lungs:  diminished  breathing  in  right 
axillary  line;  some  questionable  rales  at  the  same  place.  No  dullness. 
Abdomen  tympanitic.  General  abdominal  distention  and  tender- 
ness. No  muscular  spasm.  Tonsils  red  and  swollen.  No  patches. 
Pathology:  No  Bacillus  diphtherias  found.  Urine  slightly  turbid, 
1022;  acid  slight  trace.  Amorp.  urates  in  excess.  Few  fine  granular 
casts. 


24 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


25 


CASE  9. 


Female;   49;   married;   housework. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Two  attacks  like  the  present,  three  and  five  years  ago. 

Pres.  III. — Sixty  hours  ago,  onset  in  upper  abdomen  of  steadily 
increasing  pain,  with  acute  brief  exacerbations.  Retching  and 
vomiting  during  first  twenty-four  hours,  but  no  blood  or  intestinal 
contents  in  vomitus.  Bowels  have  not  moved  since  pain  began. 
No  chills. 

Phys.  Exam. — Well  developed  and  nourished.  Temperature, 
99. 4°;  pulse,  130,  poor  volume  and  tension.  Perfectly  conscious. 
Left  chest  negative.  Right  chest,  pleuritic  friction  rub  from  fourth 
rib  down,  in  axillary  line;  no  effusion.  Abdomen  distended.  Con- 
siderable voluntary  and  slight  involuntary  general  muscular  spasm. 
Considerable  tenderness  of  upper  abdomen,  most  marked  on  right. 
Dull  in  flanks,  elsewhere  tympanitic.  No  tumor  felt.  Visible 
peristalsis  to  right  of  median  line.  Exploratory  laparotomy  con- 
sidered, but  decided  against  chiefly  on  account  of  poor  general  con- 
dition.    High  enema;   poor  result. 

April  14th:  Condition  has  improved  slightly  during  past  ten  days. 
Considerable  tenderness  in  left  hypochondrium,  where  there  is  now 
an  indefinite,  tender,  firm  mass.  Urine,  50  to  60  ounces,  turbid, 
light  colored,  1022,  alb.  slight  trace;  pus  free  and  in  clumps.  Bowels 
moving  daily.     No  vomiting. 

April  24th:  Chill;  for  following  four  days  temperature  was  ioo° 
to  1010;  pulse,  120.  Urine  still  contains  pus.  Tumor  unchanged. 
Leucocytes  less  than  14,000. 


26 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


27 


CASE  10. 

Male;    23;    single;    clerk. 

Fam.  Hist. — Negative,  except  that  mother  is  "very  nervous." 

Prev.  Hist. — Typhoid  eighteen  months  ago.  Lasted  four  and 
one-half  months;  complicated  by  gonorrhea  and  an  "abscess  of 
testicle"  which  was  incised  during  typhoid.  Is  of  neurotic  tem- 
perament and  has  had  a  severe  nervous  shock  recently. 

Pres.  III. — Coryza  and  cough  for  three  days;  confined  to  his  room 
in  Boston.  Last  night  his  uncle  left  the  room  for  twenty  minutes 
and  returned  to  find  patient  semi-conscious  and  talking  incoherently, 
lying  on  a  lounge  where  he  had  left  him,  with  a  shotgun  by  his  side. 

Phys.  Exam. — Well  developed  and  nourished.  Slight  bronchitis. 
Heart  slightly  irregular  in  rhythm  and  force.  No  murmurs;  no 
enlargement.  Pulse,  100;  temperature,  1020.  Pupils  equal  and 
react.  Eyes  slightly  bloodshot.  Face  otherwise  normal  in  appear- 
ance. Paresis  of  left  arm  and  leg.  Left  thumb  flexed  across  palm, 
fingers  partly  flexed.  Grip  very  weak.  Left  knee-jerk  increased, 
right  normal.  Absolute  anesthesia  and  analgesia  of  left  hand, 
diminishing  in  severity  up  the  arm  and  in  leg.  Cannot  cross  left 
leg  over  right.  After  about  one  hour  begins  to  answer  some  questions 
rationally,  but  thinks  he  is  at  home  in  the  country  and  was  struck 
on  head  while  hunting.  No  injury  of  head  found,  but  soreness  in 
left  frontal  region.  No  incontinence,  nausea,  vomiting,  collapse. 
No  signs  of  violence. 


28 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


29 


CASE  ii. 

Female;   26;   married;   housework. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Negative. 

Pres.  III. — Knocked  down  this  morning  by  a  team,  twisting  right 
leg.     Pain  and  immediate  disability. 

Phys.  Exam.  (January  22d). — Heart  and  lung  negative.  Well 
developed  and  nourished.  Pupils  equal  and  react  to  light.  Marked 
odor  of  alcohol  on  breath.  On  right  leg  is  a  lacerated  wound  one 
inch  long,  three  inches  above  the  ankle,  through  which  the  broken 
ends  of  tibia  and  fibula  protrude.  Tibia  is  comminuted.  No 
other  fractures.     Urine  negative.     What  is  the  treatment  ? 

Later  Hist.  (January  23d  and  24th). — Patient  comfortable  but 
restless. 

January  25th:   Slight  rise  in  afternoon  temperature. 

January  26th:  Temperature,  1020;  pulse,  no.  No  apparent 
cause.  Lungs  and  abdomen  negative.  Wound  healing  by  first 
intention. 

On  following  two  days  no  marked  change.  On  January  29th 
patient  slightly  delirious.  Pulse  varies  from  100  to  120.  Tem- 
perature, ioo°  to  1 01  °.  At  10  p.m.  patient  complained  of  feeling 
faint;  nurse  telephoned  for  house  surgeon.  Three  minutes  later 
patient  became  unconscious;  face  gray,  with  slight  cyanosis  of  lips 
and  fingers;  extremities  cold;  pulse  imperceptible;  marked  dyspnea 
and  stertorous  respiration — 30  a  minute.  No  sweating,  cardiac 
action  irregular,  tumultuous  and  intermittent;  coarse  rales  through- 
out right  chest;  otherwise  lungs  normal;  respiration  gradually 
decreased  to  10. 


3° 


Diagnosis  ?  Prognosis  ?  Treatment 


31 


CASE  12. 

Male;  38;  married;  laborer. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Pleurisy  a  year  and  a  half  ago.  One  year  ago 
"abscess"  in  right  side  of  chest,  which  burst  spontaneously  and  has 
discharged  ever  since. 

Pres.  III. — Three  or  four  months  ago  began  to  "run  down";  short 
of  breath;  considerable  cough.  Has  steadily  grown  worse.  Vomits 
occasionally.  Has  lost  thirty  pounds.  Feels  feverish  in  the  after- 
noon. 

Phys.  Exam. — Well  developed  and  poorly  nourished.  Tempera- 
ture, 10  2. 8°;  pulse  120,  fair  volume  and  tension.  Heart  slightly  en- 
larged, apex  5th  space,  left  nipple  line.  No  murmurs.  Arteries 
stiff.  Tongue  has  a  brown  coat.  Abdomen  negative.  General 
condition  poor.  Respiration  shallow  and  labored.  Urine  negative. 
Lungs:  numerous  moist  rales.  Right  chest:  dullness  and  diminished 
respiration  below  third  rib,  front,  and  spine  of  scapula  posteriorly; 
also  diminished  voice-sounds  and  fremitus.  Sinus  in  anterior  right 
axillary  line,  5th  space,  from  which  thin  watery  pus  slowly  escapes. 
Temperature  rapidly  fell  to  normal. 


32 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


33 


CASE  13. 

Male;    59;    married;    laborer. 

Fatn.  Hist. — Negative. 

Prev.  Hist. — Negative. 

Pres.  III. — Eight  days  ago  severe  pain  began  in  left  abdomen; 
felt  chilly.  Soon  after  noticed  swelling  at  seat  of  pain,  which  grad- 
ually and  then  rapidly  increased  in  size,  with  marked  pain  and  tender- 
ness. Constipation  for  one  week.  Has  vomited  everything  eaten 
for  three  days. 

Phys.  Exam. — Well  developed  and  poorly  nourished.  Pulse  98, 
good  quality;  temperature,  102 .8°.  Tongue  slightly  coated.  Heart 
and  lung  negative.  Abdomen  on  left  side,  midway  between  ribs  and 
ilium,  large  fluctuating  tumor  dull  on  percussion,  tender,  and  sug- 
gesting fluid  under  high  tension.  Seems  attached  to  abdominal 
wall.  Hard  to  grasp  overlying  skin  between  fingers.  Examination 
causes  extreme  pain.  Abdomen  otherwise  negative.  Urine  negative. 
Vaginal  examination  negative  save  for  torn  perineum.  Leucocytosis, 
22,000. 


34 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


35 


CASE  14. 


Male;   32;   married;  waiter. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Moderate  alcohol.  Gonorrhea  fifteen  years  ago. 
Denies  syphilis.  Ulcer  on  penis,  with  suppurating  bubo  in  groin, 
eight  years  ago.  Six  months  ago  moderate  constant  pain  began 
in  epigastrium  and  right  h)Tpochondrium,  which  lasted  two  and  a 
half  months.  Soon  after,  marked  swelling  of  right  leg  below  knee 
without  pain  or  tenderness.  This  continued  two  months.  No  jaun- 
dice, no  cough.     Has  lost  flesh,  but  regained  it. 

Pres.  III. — Three  months  ago  first  noticed  that  belly  was  swollen. 
This  swelling  has  increased  and  now  causes  dyspnea.  No  pain. 
Slight  constipation.  Six  days  ago,  abdomen  tapped  and  consider- 
able liquid  removed;  has  continued  to  escape  by  drops.  Has  lost 
nine  pounds  in  weight.     Urine  negative. 

Phys.  Exam. — Well  developed  and  poorly  nourished.  Tem- 
perature, 100. 8°;  pulse  108,  good  volume  and  tension.  Heart- 
sounds  weak;  no  murmur.  Lungs  negative.  Abdomen  distended; 
dullness  in  flanks,  changing  with  position.  Liver  felt  two  fingers 
below  ribs.  General  abdominal  tenderness.  No  tumor  found. 
Straw-colored  transparent  fluid1  escapes  slowly  from  puncture  one 
inch  below  umbilicus.  Leucocytosis,  11,000.  Small  varicose  veins 
on  both  legs.  Gets  up  once  at  night  to  pass  water.  Urine  1015. 
pale,  acid,  slightest  possible  trace  albumen. 


36 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


37 


CASE  15. 

Male;   23;  single;  brass  worker. 

Fam.  Hist. — Negative. 

Prev.  Hist. — For  thirteen  years  has  had  in  left  knee  occasional 
swelling,  pain,  and  tenderness,  and  inability  to  completely  flex  or 
extend  leg.     Between  attacks,  knee  apparently  normal. 

Pres.  III.  (October  15th). — For  two  weeks  a  severe  attack  similar 
to  above.  Pain  so  severe  that  patient  could  not  sleep  or  bear  weight 
on  foot.     Patient  well  except  knee. 

Phys.  Exam. — Well  developed  and  nourished.  Pulse,  80;  tem- 
perature, 990.  Heart,  lung,  and  abdomen  negative.  Left  knee 
swollen,  tender  and  slightly  reddened;  normal  dimples  obliterated; 
patella  floats;  fluctuation  in  joint;  can  flex  leg  to  within  50  normal, 
and  almost  completely  extend  it.  Considerable  atrophy  of  leg  and 
thigh  muscles.     Walks  with  slight  limp. 

October  20th:  Much  improved.  No  fluctuation.  Temperature 
normal. 

October  25th:  Urine,  twenty-four  hours  2040  cc,  N.  1021,  acid. 
Slight  possible  trace.  Sugar  and  bile  absent.  Few  squamous  and 
neck  of  bladder  cells.  No  casts.  Occasional  small  round  cell; 
occasional  spermatozoa. 

October  29th:  No  symptom  save  slight  pain  on  pressure. 

November  3d:  Occasional  attacks  of  pain  referred  to  outer  side 
of  knee,  occasionally  accompanied  by  swelling  and  slight  tenderness. 


38 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


39 


CASE  1 6. 

Male;    73;   single;   painter. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Six  or  seven  years  ago  had  a  moderate  paralysis 
affecting  left  hand  and  foot,  said  to  have  been  due  to  lead.  Has 
partially  recovered.  No  venereal  disease;  moderate  use  of  alcohol 
and  tobacco. 

Pres.  III. — For  two  years  has  had  trouble  in  passing  water.  Diffi- 
cult to  start  the  stream,  slow  in  flowing,  frequent  micturition  and 
apparent  inability  to  completely  empty  bladder.  Has  had  acute 
retention  requiring  catheterization  several  times.  Occasionally 
blood  at  the  end  of  micturition;  frequently  dribbling  of  urine. 
Bowels  constipated.  No  severe  pain.  Mind  clear.  Has  lost  a 
little  flesh  recently. 

Phys.  Exam. — Well  developed,  fairly  nourished.  No  arcus 
senilis.  Marked  art erio -sclerosis.  Pulse  70,  regular,  fair  volume 
and  tension.  Temperature,  990.  No  glandular  enlargement. 
Lungs  normal  except  for  a  few  fine  moist  rales  in  lower  left  back 
without  dullness,  nor  diminished  vocal  nor  tactile  fremitus.  Heart 
apparently  normal.  Abdomen  soft  and  negative.  Urine  normal, 
1018;    acid;  very  slight  trace  of  albumen. 

Give  detail  of  further  examination  necessary  to  establish  a  diag- 
nosis. 

Give  in  detail  treatment  and  prognosis  of  the  various  conditions 
that  may  be  present. 


40 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


41 


CASE  17. 

Female;    16;   single;  schoolgirl. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Scarlet  fever  and  diphtheria  in  childhood.  No 
previous  attack  similar  to  present. 

Pres.  III. — Well  until  three  days  ago,  when  she  had  a  sudden 
sharp  attack  of  general  abdominal  pain,  at  first  general  and  then 
becoming  localized  in  the  right  lower  quadrant.  She  vomited  each 
evening  since,  and  has  been  much  prostrated.  Marked  tenderness 
over  seat  of  pain;  both  pain  and  tenderness  slightly  less  to-day. 
Has  felt  feverish  for  forty-eight  hours  and  bowels  have  not  moved. 
She  has  been  given  light  foods  in  moderate  quantities.  No  jaundice. 
No  chills.     Menstruation  regular. 

Phys.  Exam. — Well  developed;  fairly  nourished;  pale;  looks 
sick,  but  features  are  not  pinched.  Tongue  slightly  coated.  Lungs 
and  heart  negative.  Pulse  120,  fair  volume,  poor  tension.  Tem- 
perature, 1020.  Abdomen  distended  moderately;  considerable 
general  rigidity  and  involuntary  muscular  spasm.  Tenderness 
localized  in  right  lower  quadrant;  in  this  region  the  percussion  note 
is  dull  over  an  area  half  the  size  of  palm  of  hand,  elsewhere  tympanitic. 
No  mass  felt.  Urine  normal,  1024,  acid,  very  slight  trace  albumen. 
Few  coarse  granular  casts.  Many  leucocytes.  Many  squamous 
cells.     Leucocytes,  19,800.     Slight  leucorrhea. 


42 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


43 


CASE  1 8. 

Male;   13;  schoolboy. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Negative. 

Pres.  III. — Four  hours  ago  patient  shot  himself  with  a  small  pistol, 
loaded  with  a  blank  cartridge.  He  was  trying  to  adjust  the  action 
and  the  pistol  was  pointed  toward  his  abdomen.  He  walked  home 
and  was  brought  to  the  hospital  by  parents. 

Phys.  Exam. — Conscious  and  in  slight  pain.  Has  not  vomited 
nor  have  bowels  moved.  Has  passed  clear  normal-colored  urine 
(parents'  statement).  Has  not  eaten  since  accident,  but  has  had 
several  drinks  of  water.  Well  developed.  General  condition  good. 
Pulse,  90;  temperature,  98. 40.  Heart  and  lungs  normal.  Abdomen: 
just  under  right  costal  border,  at  edge  of  rectus  muscle,  is  a  small, 
circular,  blackened  area,  with  a  punctured  wound  in  its  center. 
Around  the  blackened  part  is  a  reddened  ring,  with  very  slight  in- 
duration, redness,  heat,  and  tenderness.  There  is  slight  abdominal 
spasm;  abdomen  not  distended  and  uniformly  tympanitic,  including 
flanks. 

Give  in  detail  the  diagnosis  and  treatment.  Would  you  advise 
immediate  celiotomy?  Why?  What  are  the  serious  dangers? 
Prognosis  ? 


44 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


45 


CASE  19. 


Female;    70;    widow;   housework. 

Fam.  Hist. — Not  obtained. 

Prev.  Hist. — Not  obtained. 

Pres.  III. — Patient  fell  down  stairs  and  was  brought  unconscious 
to  Relief  Station. 

Phys.  Exam. — Pupils  equal  and  react;  tongue  protruded  in  middle 
line;  breathing  regular,  not  noisy.  Pulse  regular,  poor  volume  and 
tension.  Heart-sounds  negative.  Abdomen  distended,  tympanitic, 
tender  in  epigastrium.  Moves  extremities.  No  vomiting.  Con- 
tused wound  three  inches  long  over  left  frontal  region.  Pulse,  100; 
temperature,  990. 

Later  Hist. — Abdominal  distention  continued.  Patient  trans- 
ferred to  Main  Hospital  two  days  after  accident.  She  was  then  con- 
scious but  vomiting.  Urine  normal  in  quality  and  quantity.  There 
was  an  indefinite  mass  in  the  epigastrium,  which  was  resistant,  non- 
fluctuating  and  tender  with  dullness  in  the  flanks,  changing  with 
change  of  position.  Vaginal  examination  negative.  Distention 
and  tenderness  of  abdomen  increasing.  Pulse,  80;  temperature, 
990.  Wound  of  head  doing  well.  No  leucocytosis.  No  move- 
ment of  bowels  for  two  days. 

Is  the  vomiting  a  serious  symptom  ? 


46 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


47 


CASE  20. 

Male;   44;   single;   salesman. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Two  attacks  of  gonorrhea,  the  last  one  five  years 
ago.  Treated  by  druggist;  left  epididymitis  followed.  Had 
chancroids  twenty  years  ago.     Uses  alcohol  to  excess. 

Pres.  III. — Stream  of  urine  has  been  diminishing  in  size  for  one  year; 
frequent  micturition  with  pain  at  the  end  of  the  act.  Last  week 
became  unable  to  pass  water  and  "opened"  the  urethra  himself  with 
aid  of  his  spectacles.  Has  had  a  very  slight  discharge  from  meatus, 
particularly  in  the  morning. 

Phys.  Exam. — Well  developed.  Pulse  strong  and  regular.  No 
glandular  enlargement.  Lungs  and  heart  normal.  Abdomen  fat 
and  negative.  Penis:  small  meatus.  Bougie  a  boule,  French  No. 
22,  passes  to  four  and  a  half  inches.  Beyond  this  nothing  can  be 
made  to  pass.  No  induration  to  be  felt  along  urethra  externally. 
Urine  normal,  1018,  acid.  No  albumen.  2  glass  test.  Many  large 
and  small  shreds  in  first  glass,  few  shreds  in  second  glass. 

What  further  examination  should  be  made  ? 


48 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


49 


CASE  21. 

Male;    28;    single;    commercial  traveler. 

Fa'm.  Hist. — Negative. 

Prev.  Hist. — Negative. 

Pres.  III. — One  hour  ago  patient  was  standing  quietly  on  the  street 
corner,  and  was  approached  by  a  stranger  who  asked  him  to  fight. 
Upon  declining  the  invitation,  the  stranger  stabbed  him  several 
times  with  what  seemed  to  be  a  large  dirty  pocket-knife;  patient  fell, 
calling  for  assistance  and  the  stranger  fled.  Police  ambulance  im- 
mediately brought  patient  to  the  hospital.  No  dressings  were  ap- 
plied by  the  police,  as  wounds  did  not  bleed  much. 

Phys.  Exam. — Well  developed  and  nourished.  Face  flushed. 
Moderate  odor  of  whisky  on  breath.  Tongue  moist  and  slightly 
coated.  Heart  and  lungs  negative.  Pulse,  100;  temperature,  990. 
Has  not  vomited  nor  passed  urine.  Three  incised  and  one  punctured 
wound  on  body.  The  incised  wounds  vary  from  one  to  two  inches 
and  are  about  half  an  inch  deep.  One  is  over  the  left  shoulder, 
the  others  at  the  occipito-parietal  and  left  temporal  regions.  Just 
below  the  costal  border  of  left  9th  rib  is  a  stab-wound,  one  inch  long, 
which  seems  to  extend  up  and  toward  the  median  line.  Nothing 
save  a  little  blood  exudes  from  it.  Abdomen  is  soft,  without  spasm 
and  tenderness,  except  at  the  wound  itself. 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


Si 


CASE  22. 

Male;    38;    widower;    carpenter. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Negative. 

Pres.  III. — Four  months  ago  pain  began  across  front  of  lower  part 
of  chest.  The  pain  was  sharp,  coming  in  short  paroxysms,  which 
were  eased  by  eructations  of  gas.  Three  months  ago  he  began  to 
vomit,  usually  once  a  day.  No  undigested  masses  of  food,  no  blood, 
no  brownish  granules  in  vomitus.  The  pain  diminished.  Laxa- 
tives in  moderate  amounts  produced  a  daily  but  somewhat  difficult 
movement  of  bowels.  No  blood  in  the  stools.  No  jaundice.  Has 
lost  fifty-six  pounds;  feels  weak.  Gave  up  work  some  weeks  ago. 
No  cough.     Urine  negative  and  normal  in  amount. 

Phys.  Exam. — Well  developed;  poorly  nourished.  Very  anemic; 
cachectic;  skin  is  harsh  and  dry.  Tongue  covered  with  a  brownish 
dry  coat.  Temperature,  ioo°;  pulse  no,  fair  volume  and  tension, 
regular.  Heart  and  lungs  negative.  Knee-jerks  present.  Abdo- 
men retracted,  parietes  thin,  very  little  subcutaneous  fat.  About 
two  inches  (5  cm.)  above  umbilicus  is  a  visible  tumor  mass,  roughly 
crescentic  in  shape,  moving  with  respiration,  extending  from  the  right 
mammary  line  to  median  line.  It  is  hard,  non-fluctuating,  some- 
what irregular,  not  tender  and  not  adherent  to  abdominal  wall.  It 
is  dull  on  percussion,  but  is  surrounded  by  an  area  of  tympany.  It 
may  be  pressed  down  upon  the  aorta  and  it  then  transmits  the  aortic 
impulse.  Hemoglobin,  20^.  Leucocytes  within  normal  limits. 
The  temperature,  with  rare  and  slight  exceptions,  continues  between 
980  and  990;  the  pulse  ranges  from  90  to  no  and  does  not  improve  in 
quality. 


52 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


OJ 


CASE  23. 


Female;   26;   married;   housewife. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Four  children,  three  dead.  Catamenia  regular  until 
eight  months  ago,  none  since.  In  past  one  and  a  half  years  has  had 
seven  attacks  similar  to  the  present  one,  the  first  coming  one  week  after 
the  birth  of  the  last  child.  Attacks  have  increased  in  severity,  pain 
becoming  more  intense  and  in  recent  attack  extending  from  original 
situation  in  right  hypochondrium  to  right  shoulder  and  even  right 
hip  and  thigh.     Jaundice  disappears  between  the  attacks. 

Pres.  III. — One  week  ago  was  seized  suddenly  with  intense  pain 
in  epigastrium  and  right  hypochondrium  radiating  to  shoulder  and 
hip.  Immediate  and  continued  vomiting.  No  real  chills  but  chilly 
sensation  with  sweating.  Marked  jaundice.  Pain  relieved  by  sub- 
cutaneous injection.  Pain  has  recurred  each  day.  Bowels  have 
moved  four  times  in  past  week. 

Phys.  Exam. — Well  developed  and  nourished.  Slightly  obese. 
Skin  and  conjunctivae  orange-yellow.  Thorax  negative.  Pulse 
100,  good  quality,  regular;  temperature,  ioo°.  Abdomen  markedly 
protuberant.  Symmetrical  tumor  from  pubes  to  three  inches  above 
umbilicus,  not  tender,  not  painful,  slightly  movable  but  not  with 
respiration.  Above  this  the  abdomen  is  lax.  Right  hypochondrium 
is  tender.  Urine  contains  bile  pigment,  otherwise  negative.  Leu- 
cocytosis,  15,000. 


54 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


:  - 


CASE  24. 


Female;    15;    schoolgirl. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Pneumonia  three  years  ago.  Neither  patient  nor 
parents  give  any  history  suggesting  spinal  trouble. 

Pres.  III. — Three  days  ago  pain  in  back;  increased  on  motion, 
especially  when  stooping.  At  this  time  parents  noticed  swelling  in 
back  to  the  right  of  median  line,  pain  and  swelling  increasing  to  date. 

Phys.  Exam. — Well  developed  and  fairly  nourished.  Pulse 
regular,  130,  good  volume  and  tension.  Heart  negative.  Tem- 
perature, 1010.  Abdomen  negative.  Lungs:  bronchial  breathing 
in  lower  left  back.  Slight  change  on  percussion.  Increased  voice 
sounds.  Occasional  rale  in  left  apex.  Evening  temperature,  ioo°. 
To  the  right  of  the  median  line,  in  the  back,  at  the  level  of  the  10th, 
nth,  and  12th  vertebrae,  is  a  fluctuant  swelling,  size  of  fist.  Free 
movement  in  hip-joints.  Patient  can  walk  without  much  pain  in 
back.     Leucocytosis,  18,400. 


56 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


5  7 


CASE  25. 


Female;    32;    married;    shopgirl. 

Fam.  Hist. — Xot  obtained. 

Prev.  Hist. — Xot  obtained. 

Pres.  III. — Patient  shot  in  the  leg  half  an  hour  ago. 

Phys.  Exam. — Absolutely  negative,  except  for  right  leg,  which 
showed  punctured  wound  with  blackened  edges  which  entered  the 
outside  of  the  right  thigh  two  inches  above  the  upper  border  of  the 
patella,  evidently  passing  through  the  external  hamstring  with  a 
wound  of  exit  on  the  inside  of  the  leg  three  inches  below  the  internal 
tuberosity7  of  the  tibia,  evidently  traversing  popliteal  space  diagon- 
ally. No  swelling.  Pulsation  of  arteries  in  foot.  No  signs  of  frac- 
ture.    Temperature  of  foot  normal. 


58 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


CASE  26. 

Male;   40;   single;   teamster. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Negative. 

Pres.  III. — One-half  hour  before  entrance,  while  riding  on  a  plank 
between  the  wheels  of  a  wagon,  patient  slipped  off.  Wheel  ran  over 
patient's  chest,  striking  right  side  first.  Unconscious.  Recovered 
consciousness  in  five  minutes.  Unable  to  rise.  Sharp  pain  in  right 
side  and  back,  which  was  continuous. 

Phys.  Exam. — Well  developed  and  nourished.  Cyanotic;  reflexes 
and  sensations  normal.  Lungs  negative.  Heart-sounds  normal. 
Pulse  100,  regular,  poor  volume  and  tension.  Right  side,  from  7th 
rib  down,  abnormal  mobility  of  ribs  with  crepitus.  Marked  tender- 
ness in  right  flank,  more  marked  toward  costal  margin.  Consider- 
able tenderness"  in  right  iliac  fossa.  Patient  put  to  bed,  with  chest- 
swathe.  Moderate  stimulation  and  morphia.  One  hour  later 
passed  12  ounces  of  urine,  being  one-quarter  or  more  in  volume 
of  blood.     Pulse  continued  to  be  weak;   rate,  no. 

Further  examination? 


60 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


6r 


CASE  27. 

Male;    16;    single. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Tuberculosis  of  the  knee.  Operation  five  years  ago. 
Anchylosis. 

Pres.  III. — One  hour  before  entrance  patient  was  thrown  from 
wagon  seat,  striking  on  his  right  side  against  a  steel  post.  Did  not 
lose  consciousness;  was  able  to  walk;  taken  to  the  police  station 
half  an  hour  later.  While  there  passed  six  ounces  of  bloody -looking 
urine.  Had  dull  pain  in  right  flank  which  gradually  increased. 
Taken  to  hospital. 

Phys.  Exam. — Face  flushed.  Pulse  equal,  regular,  rate  100,  fair 
volume  and  tension.  Diffuse  pulsation  over  whole  pericardium; 
short  systolic  murmur  not  transmitted.  Lungs  negative.  Abdo- 
men: area  of  dullness  in  right  flank  extends  halfway  to  the  median 
line  from  costal  margin  to  crest  of  ileum.  Marked  spasm  and  ten- 
derness over  this  area.  Slight  ecchymosis  over  right  ileum.  Half 
an  hour  after  entrance,  two  hours  after  injury,  pulse-rate  increased 
to  120.     Patient  passed  ten  ounces  of  urine,  one-third  blood. 


62 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


63 


CASE  28. 

Female;    17;   single;    shopgirl. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Negative. 

Pres.  III. — Ailing  for  four  weeks.  Dull,  throbbing  headache  and 
dull  pain  in  abdomen.  No  loss  of  flesh.  Worked  up  to  two  weeks 
ago.  Some  pain  in  epigastrium  after  hearty  meals;  no  vomiting. 
Bowels  regular  daily.  Abdominal  pain  was  continuous  and  kept 
her  awake  occasionally  at  night.     No  cough.     Appetite  poor. 

Phys.  Exam. — Well  developed  and  nourished.  Pupils  equal  and 
react.  Tongue:  moist  white  coat.  Pulse  88,  regular,  good  volume 
and  tension.  Temperature,  1020  at  night.  Heart  and  lungs  nega- 
tive. Abdomen  protuberant,  tense,  tympanitic  in  front,  slightly 
dull  in  flanks,  which  dullness  changes  slightly  with  position.  Slight 
fluid  wave.  Considerable  tenderness  and  some  spasm,  largely 
voluntary.      Rectal    examination  negative.      No  vaginal  discharge. 


64 


Diagnosis?  Prognosis?  Treatment? 

To  what  is  headache  due? 


CASE  29. 

Male;   36;   married;   carpenter;   Swede. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Negative. 

Pres.  III. — Two  hours  before  entrance  to  hospital  patient  slipped 
and  fell  astride  a  wooden  horse  on  which  he  was  standing,  striking 
on  his  perineum.  Got  up,  resumed  work  and  felt  all  right  except 
for  moderate  pain.  Ten  minutes  later  he  felt  something  trickling 
down  his  leg,  and  on  inspection  found  blood  coming  from  his  meatus. 
Immediately  sought  medical  advice. 

Phys.  Exam. — Well  developed  and  nourished.  Pupils  equal  and 
react.  Tongue  negative.  Heart  negative.  Pulse  good,  60;  tem- 
perature, 990.  Lungs  negative.  Abdomen  and  extremities  nega- 
tive. Inspection  of  urethra  shows  blood  trickling  from  meatus. 
Contusion  with  slight  ecchymosis  on  inner  side  of  right  thigh  and 
perineum.  No.  20  sound  passed  easily  to  bladder,  followed  by  26, 
and  then  26  catheter,  which  was  tied  in. 


66 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


67 


CASE  30. 


Female;   39;  married;  housework. 

Fam.  Hist. — Good. 

Prev.  Hist. — Scarlet  fever,  measles,  whooping-cough  in  infancy. 
"Pleurisy  and  bronchitis"  eighteen  months  ago  for  five  weeks.  No 
cough  since.  Three  years  ago  operated  for  inguinal  hernia;  no 
return.  One  year  ago  operated  for  retroverted  uterus  and  cystic 
ovary.     Pain  and  malaise  relieved  by  this  operation. 

Pres.  III. — Constipation  began  two  months  ago  followed  by 
anorexia,  loss  of  strength,  and  weight.  Constant  pain  in  left  middle 
abdomen;  this  was  at  first  relieved  by  pressure,  but  is  now  increased 
by  it.  No  vomiting,  no  jaundice,  no  blood  or  mucus  in  stools.  Slight 
increase  in  size  of  lower  abdomen;  no  change  in  micturition.  En- 
tered the  Medical  Side  of  the  Boston  City  Hospital  three  weeks  ago 
for  "bowel  trouble."  Under  rest  in  bed  and  careful  treatment 
she  improved  a  little.  She  is  seen  in  consultation  by  physicians  and 
surgeons. 

Phys.  Exam. — Thin,  fairly  developed;  good  color,  tongue  clean 
and  red,  pupils  react.  Pulse  regular,  fair  strength  and  volume, 
95;  temperature,  1020.  Thorax  negative.  Breasts  small  and  thin. 
Abdomen  distended,  tympanitic,  no  dullness  in  flanks.  Tenderness 
and  slight  spasm  in  left  lower  quadrant;  nothing  felt  on  palpation. 
Hemoglobin,  80  %;   leucocytes,  17,200. 


68 


Diagnosis  ?  Prognosis  ?  Treatment  ? 

Relation,   if  any,   of  previous  operations  to   present    condition? 
Is  constipation  important  ? 


69 


CASE  31 


Female;   48;  married;   housework. 

Fam.  Hist. — Good. 

Prev.  Hist. — One  child;  no  miscarriages.  Distress  after  eating 
for  eight  or  ten  years;  distention  and  "belching"  of  gas.  Pain,  not 
sharp  and  biting  at  intervals  of  months,  referred  to  left  hypochon- 
drium;  these  attacks  last  about  six  weeks.  Has  had  moderate  vomit- 
ing, never  large  amounts,  never  brown  or  bloody,  occasionally  green- 
ish; never  coughs.  Climacteric  two  years  ago;  usually  constipated; 
strength  good;   appetite  fair.     No  serious  illness. 

Pres.  III. — About  ten  days  ago  she  lost  her  appetite,  began  to  feel 
weak,  was  nauseated  if  she  attempted  to  eat,  but  did  not  have  pain. 
She  "felt  languid."  Last  night  she  suddenly  spat  up  a  mouthful  of 
blood;  this  morning  vomited  "two  quarts  of  blood."  She  im- 
mediately became  unconscious;  thinks  she  remained  on  the  floor 
where  she  fell  about  half  an  hour.  Blood  was  red,  not  frothy,  not 
accompanied  by  pain  or  cough.  She  has  been  dizzy  and  half  blind 
since  and  has  had  palpitation.  She  has  lost  five  pounds  in  past  ten 
days.     Nothing  unusual  in  stools. 

Phys.  Exam. — Well  developed,  fairly  nourished;  very  pale  and 
weak.  Heart  and  lungs  negative;  conscious.  Abdomen  not  dis- 
tended, no  visible  tumor;  tenderness  and  slight  voluntary  muscular 
spasm  in  upper  half  of  abdomen.  No  tumor  or  deep  resistance  felt. 
Nothing  abnormal  to  sight  or  touch  in  lower  abdomen;  universal 
tympany.  Urine  negative.  Temperature,  ioo°;  pulse  115,  regular, 
low  tension.  Leucocytes,  14,000.  Hemoglobin,  about  30%.  Reds, 
2,200,000. 


70 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


CASE  32. 


Male;    21;    single;    salesman;  Boston. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Malaria  and  typhoid  at  about  16.  Gonorrhea  four 
times;  last  time  one  month  ago;  considerable  discharge  since. 

Pres.  III. — Five  days  ago  sharp  acute  pain  in  right  groin  and  lower 
part  of  right  side  of  abdomen.  Chill  followed  by  fever.  Bowels 
constipated  for  two  days.  Dull  pain  in  right  testicle,  extending 
upward;    this  organ  swollen  and  tender. 

Phys.  Exam. — Well  developed  and  nourished.  Pupils  equal  and 
react.  Tongue:  white  coat.  Pulse  regular,  good  volume  and  ten- 
sion, no.  Temperature,  1040.  Heart  and  lungs  negative.  Ex- 
tremities negative.  Abdomen:  slight  spasm  in  right  flank.  Spasm 
and  tenderness  in  right  iliac  fossa  with  still  greater  tenderness  in 
right  groin.  Right  epididymis  swollen  and  tender  with  cord  swollen, 
tense,  and  tender.  Percussion,  uniformly  tympanitic;  slightly 
painful  in  right  lower  quadrant. 


72 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


73 


CASE  33 


Male;    30;    married;    laborer. 

Fam.  Hist. — Not  obtained. 

Prev.  Hist. — Not  obtained. 

Pres.  III. — Five  days  ago,  while  in  a  stooping  position,  patient  was 
struck  on  the  back  by  a  pile  of  lumber  and  bricks  which  toppled  over 
on  him.  Unable  to  move  except  as  to  his  arms.  Vomited  several 
times  two  days  after  injury;  required  catheterization;  seemed  to 
have  no  sensation  in  his  legs. 

Phys.  Exam. — Well  developed  and  nourished.  Pupils  equal  and 
react.  Tongue  protrudes  straight.  Pulse  equal,  regular,  good 
volume  and  tension,  rate  100.  Temperature,  100. 50.  Heart  and 
lungs  negative.  Knee-jerks  absent.  No  Rabinski.  Complete 
anesthesia  to  pain,  "tough  and  bony"  sensation  below  the  iliac 
crests,  including  perineum.  Retention  of  urine  and  feces.  Mod- 
erate distention  of  abdomen.  No  kyphosis  or  irregularity  of  spines. 
No  leucocytosis.     Can  move  legs  slowly  and  with  effort. 


74 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


75 


CASE  34. 


Female;   33',   married;   housekeeper. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Negative. 

Pres.  III. — Twenty-four  hours  before  entrance,  while  at  home, 
patient's  husband  threw  her  on  the  floor  and  kicked  her  in  the  left 
side  several  times.  Patient  stated  that  it  "hurt  her  some  "  at  the  time, 
but  she  paid  little  attention  to  it  and  went  to  bed  shortly  after.  Half 
an  hour  later  was  awakened  by  pain  in  the  left  side  and  was  obliged 
to  He  on  the  other  for  relief.  Next  morning  was  seen  by  a  doctor 
who,  because  of  continued  increasing  pain  in  this  region,  recom- 
mended her  transfer  to  hospital. 

Phys.  Exam. — Well  developed  and  nourished.  Condition  of 
moderate  shock,  skin  being  cold  and  mucous  membranes  rather 
pale.  Patient  lies  on  the  right  side  with  the  left  knee  flexed.  Pupils 
equal  and  react.  Lungs  negative.  Heart-sounds  faint,  no  mur- 
murs. Pulse  90,  weak,  poor  volume  and  tension.  Abdomen: 
slightly  protuberant,  lax,  no  spasm,  very  tender  in  left  upper  quadrant 
with  an  indefinite  mass.  Signs  of  free  fluid  in  the  abdominal  cavity. 
White  count,  8900.  Urine :  no  blood,  no  albumin.  Bowels  have  not 
moved  nor  has  patient  vomited.  Temperature  normal.  Hemo- 
globin 60%.     What  further  examination? 


76 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


n 


CASE  35. 


Male;  20;  single;  painter. 

Fam.  Hist. — Negative. 

Prev.  Hist. — For  one  year  patient  has  had  some  pain  in  epigastric 
region  after  meals,  not  all  the  time  but  occurring  in  the  form  of 
attacks  lasting  from  three  days  to  a  week.  Never  vomited,  except 
as  a  result  of  some  excess.  Slight  loss  of  flesh  and  strength  the  past 
six  months.     Otherwise  always  well  and  able  to  work. 

Pres.  III. — One  week  dull  pain  in  right  hypochondrium;  twenty- 
four  hours  ago  sharp  pain  below  right  costal  margin,  shooting  toward 
right  scapula.  Chills  lasted  an  hour;  vomited  once.  Bowels  con- 
stipated for  the  last  week.     Urine  negative.     White  count,  16,000. 

Phys.  Exam. — Well  developed  and  fairly  nourished.  Pupils 
equal  and  react.  Temperature,  100. 30;  pulse,  70.  Sclera  slightly 
jaundiced.  Tongue:  white  coat.  A  faint  lead  line  on  gums. 
Heart:  diastolic  murmur  at  apex,  not  transmitted.  Abdomen: 
no  distention;  slight  general  spasm;  considerable  spasm  and  tender- 
ness in  right  hypochondrium  extending  to,  but  not  below,  McBur- 
ney's  point.     No  mass. 


78 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


■-' 


CASE  36. 

Female;   13;  single. 

F am.  Hist. — Negative. 

Prev.  Hist. — Negative. 

Pres.  III. — Ten  days  ago  fell  while  running  and  bruised  right 
thigh,  outer  side,  just  below  hip-joint.  Next  day,  while  at  school, 
it  began  to  pain.  Went  home  and  found  thigh  somewhat  swollen. 
Swelling  and  pain  increased.  Remained  in  bed.  Felt  slightly  fever- 
ish; no  chill. 

Phys.  Exam. — Well  developed  and  nourished.  Pupils  equal  and 
react.  Tongue:  slight  white  coat,  dry.  Pulse  120,  good  volume 
and  tension.  Heart  negative.  Lungs  negative.  Abdomen  nega- 
tive. Right  thigh  swollen,  hot,  tender  as  to  its  upper  two-thirds. 
Outer  aspect,  three  inches  below  trochanter,  shows  point  of  greatest 
swelling  and  tenderness,  with  slight  fluctuation.  No  glands  in 
groin.  Pain  is  evidently  rather  severe.  Temperature,  990.  Flax- 
seed poultices  thirty-six  hours.  At  the  end  of  that  time,  pulse  100, 
temperature  1040.  Local  condition  practically  the  same.  Leuco- 
cytes, 15,500. 


So 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


Si 


CASE  37. 


Male;   27;   single;   conductor. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Always  well. 

Pres.  III. — For  five  days  increasing  swelling  in  throat,  region  of 
both  tonsils.  Inability  to  open  mouth.  Pain  much  worse  on  right 
side.     No  chill. 

Phys.  Exam. — Pupils  widely  dilated,  do  not  react.  Pulses  equal, 
slightly  irregular  in  rhythm,  good  volume  and  tension.  Heart: 
normal  in  size;  no  murmurs.  Throat  shows  general  reddening, 
slight  swelling  of  both  tonsils.  Bimanual  examination  with  finger 
in  mouth  shows  tender  indurated  mass  in  the  neck  below,  and  to  the 
base  of,  the  tongue.  Twenty-four  hours  later  patient  has  com- 
plained of  continuous  severe  pain.  Examination  of  the  throat 
same  as  at  entrance.  Severe  pain  on  swallowing.  Pulse,  120; 
temperature,  103. 50,  evening.  Leucocytes,  20,000.  Some  tender- 
ness under  chin. 


82 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


83 


CASE  38. 


Female;    46;    married;    housekeeper. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Negative. 

Pres.  III. — Rather  nervous  temperament.  For  past  two  months 
attacks  of  sharp  pain  in  epigastric  region,  not  referred.  Attacks 
last  two  to  four  days,  and  occur  four  or  five  times  a  month.  Always 
accompanied  by  chill  and  vomiting;  onset  always  sudden.  Jaundice 
always  present  during  attacks,  but  varies  in  amount  and  always 
subsides  with  the  attack.  Last  attack  three  days  ago.  Bowels 
move  daily,  rather  light  colored.     Menstruation  regular. 

Phys.  Exam. — Sclera  slightly  jaundiced.  Fairly  developed.  Has 
not  lost  flesh.  Abdomen  not  protuberant,  soft,  tympanitic,  no  spasm. 
Slight  tenderness  confined  to  the  epigastric  region.  No  tumor. 
Pulse,  90;   temperature,  99. 50.     Urine  negative.      No  leucocytosis. 


Diagnosis  ?  Prognosis  ?  Treatment  ? 

Treatment  of  individual  attacks?      Of  underlvinsc  condition? 


§5 


CASE  39. 

Male;  42;  married;  laborer. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Smallpox  at  16.  Four  and  a  half  years  ago  com- 
pound fracture  of  left  leg  low  down.  Wounds  cleaned  and  dressed; 
fracture  reduced;  gangrene.  Five  weeks  later  amputation,  middle 
and  lower  thirds.  Necrosis  of  skin-flap.  Discharged  with  large, 
sluggish,  granulating  wound.  At  no  time  since  has  it  been  entirely 
healed.  More  or  less  pain.  Bought  a  wooden  leg;  never  able  to 
use  it.     Could  not  stand  pressure. 

Pres.  III. — Three  weeks  ago  wound  and  stump  grew  worse  and 
more  painful. 

Phys.  Exam. — Obese.  Arteriosclerosis.  Pupils  equal  and  react. 
Pulse  regular,  good  volume,  rather  high  tension.  Lungs  negative. 
Abdomen  negative.  Left  leg  amputated,  middle  and  lower  thirds. 
Lower  five  inches  of  stump  red,  indurated,  slightly  tender.  Sinus 
over  the  end  of  bone,  one  inch  deep.  Sloughing  area  about  it,  size 
of  a  quarter.  Small  sloughing  ulcer,  size  of  nickel;  anterior  surface 
of  stump,  two  inches  from  end.  At  this  point  skin  is  adherent  to 
bone. 


86 


Diagnosis  ?  Prognosis  ?  Treatment  ? 

Probable  cause  of  previous  gangrene? 


8? 


CASE  40. 


0  Female;    36;    married;    seamstress. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Always  well  except  for  three  miscarriages. 

Pres.  III. — Six  months  ago  cough  with  some  expectoration  in  the 
morning.  Hoarseness  began  four  months  ago;  has  grown  steadily 
worse.  Has  lost  fifteen  pounds.  Occasionally  sweats  a  little  at 
night;  no  subjective  fever.  Seven  weeks  ago  a  swelling  appeared 
on  left  side  of  neck,  extending  to  median  line,  which  increased  in 
size,  making  swallowing  difficult  for  past  two  weeks. 

Phys.  Exam. — Well  developed  and  nourished.  Hoarse  voice, 
speaks  in  a  coarse  whisper.  Pupils  normal.  Tongue:  slight  dry 
coat.  Pulse  regular,  fair  volume  and  tension,  100.  Heart  abso- 
lutely negative.  Lungs:  dullness,  increased  vocal  and  tactile  frem- 
itus, a  few  crackling  rales  and  prolonged  expiration  in  left  apex. 
Abdomen  negative.  Extremities  negative.  Neck  shows  swelling 
extending  from  clavicle  to  top  of  thyroid  cartilage,  size  of  palm  of 
hand,  mostly  to  the  left  side,  indurated,  tender,  slightly  red,  fluc- 
tuant. 

Further  examination? 


88 


Diagnosis  ?  Prognosis  ?  Treatment  ? 

What  effect  does  pulmonary  condition  have  upon  treatment  ? 


89 


CASE  41. 

Female;    60;    widow. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Fourteen  children  and  two  miscarriages.  Moderate 
constipation. 

Pres.  III. — Has  noticed  swelling  of  entire  abdomen  for  two  weeks, 
increasing  more  rapidly  past  four  days.  Not  much  pain.  Always 
somewhat  constipated.  Past  three  days  no  movement.  Cathar- 
tics freely  used.     Little  headache;    no  vomiting. 

Phys.  Exam. — Well  developed  and  fairry  nourished.  Tongue: 
moist,  slight  brown  coat.  Pulses  regular,  fair  volume  and  tension, 
rate  80.  Heart  normal  except  for  slight  irregularity.  Lungs  nega- 
tive except  for  a  few  moist  rales  in  left  lower  back.  Abdomen  not 
much  distended  above  umbilicus.  Below  this  point,  dome-shaped 
eminence  extending  to  pubes.  No  mass  felt.  Tympanitic  through- 
out. Visible  peristalsis  and  gurgling,  no  spasm,  no  rigidity.  Very 
little  tenderness.  Vaginal  and  rectal  examinations  negative.  Tem- 
perature normal.  Treatment:  high  enema  gave  very  slight  result; 
no  gas;  next  two  days  efforts  to  move  bowels  with  cathartics  and 
enemata  failed.  Abdominal  distention  the  same.  Temperature 
and  pulse  same.  General  condition  as  evidenced  by  facies  not  quite 
so  good. 

Further  examination? 


90 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


91 


CASE  42. 

Child;    3^  years. 

Fam.  Hist. — Good. 

Prev.  Hist. — Good. 

Pres.  III. — Twenty -four  hours  ago  pulled  over  a  kettle  containing 
water  almost  at  the  boiling  point.  The  water  struck  the  child's 
woolen  clothing  over  her  right  arm  and  chest.  The  clothes  were 
immediately  cut  off  and  a  physician  covered  the  burns  with  bicar- 
bonate of  soda  and  later  with  a  dressing  of  lime-water  and  olive  oil. 
The  child  suffered  severe  pain  for  two  or  three  hours,  but  slept 
fairly  well  after  having  had  10  grains  of  bromid  of  soda.  Three 
hours  ago  it  was  noticed  that  the  child  was  feverish;  one  hour  later 
she  had  a  severe  convulsion,  clonic  and  then  tonic,  legs  and  arms 
extending,  thumbs  turned  inward,  moderate  cyanosis,  tongue  pro- 
truded but  not  bitten,  nystagmus.  When  the  convulsion  passed  the 
child  was  unconscious,  and  continued  so,  a  similar  convulsion  be- 
ginning now  again.     No  involuntary  micturition^or  defecation. 

Phys.  Exam. — Well  developed  and  nourished  child,  unconscious, 
in  convulsions,  cyanotic.  Respiration,  50;  pulse  150,  fair  strength, 
regular;  temperature,  105. 8°.  Nystagmus,  pupils  widely  dilated, 
do  not  react.  Said  to  have  passed  but  little  urine:  catheterized; 
jfiij  slightly  high-colored  urine  obtained  which  does  not  contain 
albumen.  One-half  area  of  right  arm  burned,  epidermis  destroyed, 
deep  layer  of  skin  reddened,  devitalized  and  dry.  A  similar-looking 
area,  roughly  circular,  five  inches  in  diameter  on  right  chest.  None 
of  the  water  or  steam  struck  the  child's  face.  Has  been  given  rr^ij 
tincture  aconite  every  two  hours,  a  little  brandy,  and  a  small  amount 
of  water  bv  mouth. 


92 


Diagnosis?  Prognosis?  Treatment? 

Is  the  case  immediately  or  remotely  dangerous?  What  will  be 
the  future  treatment  of  the  burns?  Would  you  continue  the 
aconite,  and  why?  Is  this  condition  a  common  complication  of 
burns?     Was  the  original  treatment  of  the  burned  surface  good? 


93 


CASE  43. 


Male;   39;   married;    electrician. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Stomach  trouble  for  two  years — that  is,  frequently 
pain  after  meals;  much  worse  past  five  weeks;  always  pain  after 
meals;  occasional  vomiting;  no  blood.  Lost  twenty  pounds  of  flesh 
in  past  month. 

Pres.  III. — Two  days  ago  had  a  slight  attack  of  faintness.  That 
morning  noticed  stools  were  black  and  offensive;  very  weak  toward 
evening.  Next  day  unable  to  get  up.  Five  hours  ago  patient  had 
another  attack  of  weakness  with  increasing  pallor.  Began  to  feel 
restless.  Abdominal  pain;  nausea;  no  vomiting.  Given  a  sub- 
cutaneous injection,  character  unknown,  before  entrance  to  hospital. 

Phys.  Exam. — Well  developed  and  nourished.  Very  pale;  anxious 
expression;  mucous  membranes  blanched;  restless.  Pupils  small, 
do  not  react.  Tongue:  dry,  slight  brown  coat.  Pulse  regular,  100, 
fair  volume  and  tension.  Heart  negative.  Lungs  negative.  Ab- 
domen tender  in  epigastric  region;  slight  general  spasm;  no  signs 
of  fluid. 


94 


Diagnosis  ?  Prognosis  ?  Treatment  ? 

Probable  significance  of  pupils? 


95 


CASE  44. 


Male;    41;    married;    cook. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Gonorrhea  twenty  years  ago.  Slight  rheumatism 
two  years  ago,  not  accompanied  by  chills  or  sweats.  Habits  mod- 
erate. 

Pres.  III. — About  one  week  ago  was  seized  with  sudden  pain  which 
started  in  small  of  back  and  shot  around  to  the  front.  Pain  ex- 
tremely severe,  lasting  but  a  short  time;  slept  well  and  next  day 
passed  three  small  stones  from  meatus.  No  blood.  Passed  water 
thirty  hours  ago  and  has  not  been  able  to  pass  any  since.  Pain  in 
lower  front  abdomen,  not  elsewhere.     Has  not  vomited. 

Phys.  Exam. — Well  developed  and  nourished.  Conscious. 
Pupils  react,  tongue  slightly  coated.  Pulse  regular,  fair  volume  and 
tension,  not  rapid.  General  condition  good.  Temperature  normal. 
Lungs  normal.  Heart:  apex  not  seen;  percussion  and  auscultation 
show  it  to  be  in  the  5th  space,  one  and  a  half  inches  outside  nipple 
line;  no  thrill;  one  inch  dullness  to  right  of  sternum.  Soft  systolic 
murmur  at  apex  transmitted  to  axilla  but  not  heard  at  back.  Second 
pulmonic  accentuated.  Abdomen  tense  and  distended ;  dullness 
over  pubes  halfway  to  umbilicus.  Slight  shifting  dullness  in  flanks. 
Urine  bloody,  1010,  neutral.  Albumen  a  trace;  sediment,  much 
normal  blood,  considerable  large  white  cells  on  day  after  entrance. 
Penis:  meatus  very  small;  palpation  reveals  a  hard,  resistant,  non- 
tender  mass  apparently  within  the  urethra,  one  inch  from  meatus. 


06 


Diagnosis  ?  Prognosis  ?  Treatment  ? 

In  what  way  does  cardiac  condition  affect  the  case? 


97 


CASE  45. 


Male;   77;  married;  laborer. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Not  obtained. 

Pres.  III. — Slightly  constipated  for  four  or  five  weeks;  otherwise 
about  the  house  as  usual.  Four  days  ago  good  movement  of  bowels 
in  evening.  Since  then  nothing  except  little  gas  first  two  days,  past 
two  days  nothing.  Four  days  ago  discovered  hard  irreducible  lump 
in  left  groin,  size  of  egg,  slight  pain  attracting  his  attention.  Pain 
gradually  increased  with  vomiting  twice  two  days  ago,  several  times 
yesterday  and  to-day.  Patient  states  that  he  never  knew  he  was 
"ruptured." 

Phys.  Exam. — Well  developed  and  fairly  nourished.  Looks 
somewhat  anxious.  Considerable  sclerosis.  Pulse  good  volume, 
fair  tension,  80;  temperature  normal.  Heart  and  lungs  negative. 
Abdomen  moderately  distended,  rigid  with  involuntary  spasm, 
slightly  tender.  Hard  lump  in  left  groin,  apparently  below  Pou- 
part's  ligament,  size  of  egg.  Not  tympanitic,  irreducible.  Treat- 
ment: high  enema,  good  result.  Operation:  under  cocaine,  tumor 
found  to  be  strangulated  omentum  through  femoral  opening. 
Omentum  black.  Excised.  Skin  and-  muscle  closed  through-and- 
through  sutures.  Half  an  hour  after  operation,  while  left  alone  for 
a  few  minutes,  patient  stood  on  his  feet  by  side  of  bed.  Perfectly 
comfortable  through  night  and  following  day  with  normal  tempera- 
ture and  pulse  below  90.  Second  day  after  operation  patient  vomited 
three  times;  vomitus  foul,  fecal.  Repeated  enemata  gave  no  result. 
Abdominal  distention  appeared  and  rapidly  increased  with  tender- 
ness and  pain.  Anxious  look  returned.  Pulse  continued  to  be  good, 
at  90  to  100;  temperature  normal. 


98 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


99 


CASE  46. 

Female;   46;   married;  housekeeper. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Pneumonia  in  childhood.  Rheumatism  at  6,  in 
bed  five  weeks.  Erysipelas  at  the  same  time.  Four  children,  no 
miscarriages.  Catamenia  continue  regular.  Has  had  cough  with 
yellowish  expectoration  six  months. 

Pres.  III. — Two  weeks  ago  this  became  worse.  Had  a  chill,  felt 
feverish.  In  bed  since  then.  Bowels  have  moved  every  day,  some- 
times three  or  four  times  a  day.  Appetite  poor.  Thirst  excessive. 
No  vomiting.  Indefinite  general  abdominal  pain  for  these  two  weeks. 
No  specially  tender  place.  Lost  "considerable"  flesh.  No  night- 
sweats. 

Phys.  Exam. — Well  developed  and  poorly  nourished.  Pale. 
Pupils  equal  and  react.  Tongue:  dry,  slight  white  coat.  Pulse 
regular,  fair  volume  and  tension,  96;  temperature,  103.50.  Heart 
negative.  Lungs:  dullness  in  both  apices  with  bronchial  breathing; 
crackling  rales,  more  on  right.  Abdomen:  rigid,  tympanitic,  con- 
siderable general  tenderness  and  spasm,  liver  not  felt.  Spleen  not 
felt  but  slightly  enlarged  by  percussion.  White  count,  8000.  Widal 
negative. 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


IOI 


CASE  47. 


Female;    22;   married. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Two  years  and  a  half  ago  operation  for  ventral  sus- 
pension. Separation  of  pelvic  adhesions  which  had  evidently  fol- 
lowed mild  pelvic  inflammation.  Small  cyst  removed  from  left  and 
one  from  right  ovary.  Both  ovaries  and  tubes  slightly  swollen. 
Patient  has  been  married  three  years;  has  never  been  pregnant. 

Pres.  III. — Two  weeks  ago  painful  and  profuse  menstruation, 
which  lasted  about  a  week.  Two  days  ago  return  of  pain  in  pelvic 
region.     No  movement  of  bowels  for  three  days.     No  vomiting. 

Phys.  Exam. — Well  developed  and  nourished.  Pupils  equal  and 
react.  Tongue:  slight  white  coat.  Pulse  regular,  95;  temperature, 
1020.  Heart  and  lungs  negative.  Abdomen  slightly  distended. 
Some  general  spasm  and  tenderness,  both  being  a  little  more  marked 
in  the  lower  half  of  abdomen,  but  about  equal  as  to  sides.  Vaginal 
examination  reveals  nothing  except  increased  resistance  on  right  side. 
Few  hours  after  entrance  patient  had  excellent  result  from  high 
enema.  Passed  a  fairly  comfortable  night.  Twenty -four  hours  later 
(being  thirty-six  hours  after  patient  was  first  seen)  pulse,  130;  tem- 
perature, 990.  Distention  somewhat  increased.  Slight  dullness 
in  lower  half  of  abdomen.  Tenderness  and  spasm  somewhat  in- 
creased. Pain  remained  about  the  same,  according  to  amount  and 
character.     Patient  looks  anxious. 


T02 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


: :  : 


CASE  48. 


Male;    30;    Chinese;    single;    laundryman. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Negative.     Denies  venereal  diseases. 

Pres.  III. — Three  months  ago  noticed  moderate  soreness  on  inner 
side  of  left  thigh,  just  above  knee.  Thinks  he  may  have  struck  it, 
but  has  no  recollection  of  any  particular  accident.  This  area  has 
gradually  swollen,  accompanied  with  very  slight  pain  and  tender- 
ness. Recently  there  has  been  slight  limitation  of  motion.  He  has 
not  had  a  chill  and  has  not  felt  feverish,  though  his  temperature 
has  been  slightly  elevated  on  at  least  one  occasion.  He  has  con- 
tinued his  work  until  three  days  ago. 

Phys.  Exam. — Well  developed  and  nourished;  has  not  lost  flesh. 
Heart,  lungs,  abdomen,  and  urine  negative.  Left  thigh,  inner 
aspect  just  above  condyle,  a  moderate  swelling,  firm  and  possibly 
slightly  fluctuating,  slightly  tender,  not  reddened;  apparently  not 
adherent  to  the  bone,  though  appears  to  be  attached  to  the  soft  parts 
directly  above  the  bone.  Knee-joint  normal  except  for  slight  limita- 
tion of  active  motion.  Surface  temperature  not  increased.  No 
leucocytosis.  No  glands  in  groin.  Pulse  So,  regular,  strong;  tem- 
perature, 990  (evening).     Appetite  good. 


104 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


CASE  49. 


Female;    35;    single. 

Fam.  Hist. — Good. 

Prev.  Hist. — Has  had  "dyspepsia"  for  several  years;  typhoid 
(moderate  severity)  ten  years  ago.     Never  jaundiced. 

Pres.  III. — While  under  treatment  for  nervous  dyspepsia,  com- 
plicated by  insomnia  and  moderate  neurasthenia,  was  attacked  bv 
sudden,  severe,  burning  pain  referred  to  epigastrium.  Immediate 
vomiting  of  dark  greenish  thin  liquid — no  blood  (either  now  or  at 
any  previous  time).  At  the  end  of  the  vomiting  patient  became 
unconscious,  had  a  slight  tonic  convulsion;  no  biting  of  tongue,  no 
foaming  at  lips.  Recovered  consciousness  and  vomited  twice  again, 
then  becoming  semi-conscious,  still  complaining  of  severe  pain. 
Has  previously  been  passing  sixty  to  eighty  ounces  of  urine  of  low 
specific  gravity  and  without  albumen. 

Phys.  Exam. — Fairly  developed  and  nourished;  pupils  equal  and 
react;  skin  brown;  expression  of  pain  but  not  anxiety;  conscious 
but  disinclined  to  speak;  frequent  large  eructations  of  gas  from 
stomach.  Heart  and  lungs  negative.  Abdomen  tender,  slight  mus- 
cular spasm  in  upper  half,  no  dullness,  tympanitic  everywhere; 
no  jaundice.  Pulse  regular,  poor  volume  and  ranging  from  70  to 
80.  Temperature  normal.  Severe  headache;  pupils  equal  and 
react.  Moderate  pressure  on  abdomen  is  not  unpleasant.  Pain 
extends  upward  and  to  the  left;  legs  not  drawn  up.  Urine  but 
fifteen  ounces  in  past  twenty  hours,  high  color,  1014,  neutral,  no 
albumen. 


106 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


10: 


CASE  50. 


Female;   23;   married;   housework. 

Fant.  Hist. — Negative. 

Prev.  Hist. — One  child,  two  years  old;  no  miscarriages.  For 
about  one  year  irregular  pain  in  lower  abdomen;  constant  leucorrhea; 
occasional  frequent  micturition.  Has  felt  poorly  but  has  done  her 
own  housework  until  three  weeks  ago. 

Pres.  III. — Pain  and  tenderness  increasing  and  referred  to  lower 
abdomen,  more  particularly  on  the  right.  Pain  moderately  severe, 
dull,  not  sharp  or  stabbing  in  character.  Constipated  but  did  not 
vomit.  No  cough.  Admitted  to  Medical  Ward.  Mild  diet, 
cathartics,  rest  in  bed,  sedatives.  General  condition  improved 
somewhat,  but  abdominal  symptoms  persisted. 

Phys.  Exam. — Pale,  fairly  developed,  poorly  nourished.  Heart 
and  lungs  negative.  Tongue  coated.  Pulse  regular,  fair  strength, 
80;  temperature,  99. 50.  Urine  negative.  Abdomen  not  distended. 
Striae  of  pregnancy  present.  Moderate  tenderness  in  right  lower 
quadrant.     No  leucocytosis.     No  tumor  felt. 

Further  examination? 


108 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


109 


CASE  51. 


Male;    36;    married;    teamster. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Negative.  Denies  venereal;  moderate  drinker. 
Has  been  teaming  for  a  wool  firm. 

Pres.  III. — Five  days  ago  noticed  a  pimple  about  size  of  a  pin's 
head  on  right  upper  cheek.  It  gradually  increased  in  size  but  without 
much  pain.  Two  days  ago  the  "pimple"  was  opened  in  an  out- 
patient department.  Since  then  it  has  increased  more  rapidly  and 
the  swelling  has  partially  closed  the  eye. 

Phys.  Exam. — Well  developed  and  nourished.  Pupils  equal  and 
react.  No  general  glandular  enlargement.  Heart  and  lungs  nega- 
tive. Urine  normal.  Abdomen  and  genitals  normal.  Knee-jerks 
normal.  Over  right  malar  bone  is  a  hard,  brownish,  ulcerated 
area,  size  of  five-cent  piece,  around  which  is  some  redness  and  several 
vesicles.  Much  swelling  and  edema  about  eye  which  is  closed  tight. 
Not  much  pain  or  tenderness. 

Further  examination? 


no 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


in 


CASE  52. 


Male;   26;   married;   carpenter. 

Fam.  Hist. — Good,  except  that  a  half-sister  died  of  phthisis. 

Prev.  Hist. — Good.  Always  well;  denies  venereal;  no  alcohol. 
Has  been  married  six  months.  Just  before  marriage  noted  for  the 
first  time  a  small  painless  lump  in  right  testicle. 

Pres.  III. — Five  months  ago  suddenly  began  to  feel  weak,  with 
headache,  fever,  and  anorexia;  constipation  followed  by  slight 
diarrhea,  which  persisted;  general  malaise.  Was  unable  to  work, 
but  did  not  stay  in  bed  for  more  than  a  day  or  two.  After  four  or 
five  weeks  he  began  to  feel  better  and  his  appetite  returned.  He 
resumed  work  for  a  while,  gained  weight  and  felt  fairly  well.  Then 
pain  in  back  appeared,  soon  becoming  very  severe,  and  was  notice- 
ably worse  at  night;  it  was  referred  to  left  lower  back.  Since  then 
has  been  "good  for  nothing,"  though  not  confined  to  bed.  In  past 
few  weeks  has  noticed  slight  increased  frequency  of  micturition,  but 
nothing  abnormal  in  appearance  of  urine.  No  chill,  nausea,  vomit- 
ing, or  sweating. 

Phys.  Exam. — Fairly  developed  and  nourished;  cheeks  slightly 
flushed;  stands  with  rigid  back  and  walks  with  left-sided  limp,  which 
is  not  entirely  typical  of  either  hip-  or  spine-disease.  Eyes  clear; 
tongue  clean.  Heart  and  lungs  negative.  A  small  specimen  of 
urine  passed  at  10.30  a.  m.  was  1020,  pale,  slightly  acid;  no  albumen. 
Right  testis  somewhat  enlarged,  slightly  tender;  on  posterior  surface 
a  nodule,  three-quarters  of  an  inch  in  diameter,  firm,  not  movable, 
slightly  tender,  non-fluctuating.  Back  is  rigid  in  lumbar  region,  and 
erector  spinae  muscles  are  tense,  but  there  is  no  knuckle  in  the  spinal 
column,  and  motion  is  little  if  at  all  limited.  Abdomen  relaxed; 
in  upper  left  quadrant  is  a  tumor — tense,  tender,  smooth,  convex 
downward,  projecting  below  the  edge  of  the  ribs.  From  this  tumor 
an  indurated  cord  runs  downward  and  inward  in  a  direction  similar 
to  that  of  the  ureter.  The  right  kidney  is  palpable  and  slightly 
tender.  Abdomen  otherwise  negative.  Rectal  examination  demon- 
strates a  slightly  tender  prostate,  which  is  not  enlarged.  Pulse,  80; 
temperature,  990. 

Further  examination? 


IT2 


Diagnosis  ?  Prognosis  ?  Treatment  ? 

Prognosis  with  and  without  treatment? 


"3 


CASE  53. 


Female;   37;   married;   laundress. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Five  children,  last  one  two  years  ago;  no  miscar- 
riages. Has  always  been  of  a  nervous  temperament.  Occasional 
attacks  of  indigestion,  that  is,  once  in  three  months  has  what  she 
calls  bilious  attack. 

Pres.  III. — Sense  of  soreness  in  lower  part  of  abdomen  for  two 
weeks.  Bowels  loose,  two  to  three  movements  daily.  Vomited 
half  a  dozen  times  in  past  two  weeks.  Had  a  slight  chill  this  morn- 
ing. Was  struck  a  light  blow  on  the  stomach  three  days  ago,  fol- 
lowed by  some  abdominal  pain.  In  bed  past  three  days.  Cat- 
amenia  present  two  weeks  ahead  of  time.  Patient  says  she  has  had 
frequent  headaches  of  a  dull  character  in  frontal  and  occipital  regions. 
Occasionally  has  attacks  of  vertigo.  Has  cramps  in  the  legs  at  night. 
Is  very  "nervous." 

Phys.  Exam. — Well  developed  and  nourished;  troubled  expres- 
sion; does  not  look  sick.  Pupils  equal  and  react.  Tongue:  slight 
white  coat.  Pulse  regular,  rather  high  tension,  120;  temperature, 
1010.  Right  leg  and  right  arm  moderately  anesthetic.  Heart 
negative.  Lungs  negative.  Abdomen  considerably  distended  with 
marked  general  voluntary  spasm  and  tenderness;  rigidity  almost 
board-like.     No  leucocytosis. 


114 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


"5 


CASE  54. 


Male;  48;  married;  woodworker. 

Fant.  Hist. — Negative. 

Prev.  Hist. — Moderate  use  of  alcohol;  otherwise  negative. 

Pre s.  III. — One  year  ago  noticed  a  swelling  near  right  sterno- 
clavicular joint,  which  burst,  discharging  thin  pus,  one  month  later 
The  discharge  has  continued  since  that  time,  though  patient  has  been 
treated  in  an  outpatient  department  for  nearly  eight  months.  He 
has  had  at  least  one  incision,  presumably  for  drainage,  in  the  neck . 
The  scar  of  this  incision  is  in  the  middle  line.  About  eight  days  ago 
a  swelling  appeared  at  the  upper  part  of  the  sternum.  This  became 
reddened  and  gradually  developed  fluctuation.  There  was  very 
slight  pain  and  moderate  tenderness  accompanying  it. 

Phys.  Exam. — Well  developed  and  nourished.  Pupils  equal  and 
react.  Tongue  clean.  Pulses  equal  and  regular,  fair  volume,  high 
tension.  Heart  area  normal,  no  murmurs.  Abdomen  soft,  not 
tender  nor  distended,  tympanitic  everywhere  save  in  left  flank,  where 
it  is  dull.  Extremities  negative.  Knee-jerks  present.  Slight 
general  glandular  enlargement.  Urine  negative.  Pulse,  90;  tem- 
perature, 99. 5°  (night).  Swollen  and  reddened  area  over  upper 
sternum  about  the  size  of  palm  of  hand.  Probe  reaches  bare  bone 
through  a  small  sinus. 


116 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


«7 


CASE  y£ 

Male;    34;    single;    salesman. 

Fam.  Hist. — Father  died  of  a  "shock." 

Prev.  Hist. — Gonorrhea  eight  years  ago.  Still  has  gleety  discharge 
at  times.     Moderately  alcoholic. 

Pres.  III. — Fell  down  a  flight  of  stairs  to-day,  injuring  head,  left 
shoulder,  and  right  thumb.  Was  unconscious  for  some  hours. 
Coughs  frequently. 

Phys.  Exam. — Conscious.  Well  developed  and  nourished. 
Pulse :  good  volume  and  tension,  not  frequent  nor  very  slow.  Pupils 
equal  and  small,  react  slowly  both  to  light  and  accommodation. 
Heart  negative;  no  rales  in  lungs.  Abdomen  not  tender,  tympanitic. 
Moves  all  extremities  except  right  arm,  and  this  apparently  due  to 
pain.  Knee-jerks  present;  no  anesthesia.  Bleeding  from  left  ear. 
Pain  in  right  shoulder;  no  crepitus  nor  abnormal  mobility.  Tem- 
perature normal.  Urine  negative.  Two  days  later  got  out  of  bed 
in  an  aimless  fashion  "to  catch  some  rats."  Fingers  tremulous, 
looks  anxiously  about  ward,  does  not  sleep.  Anorexia.  Talks  in  a 
low  voice  to  himself  part  of  time.  Reflexes  lively.  No  retraction 
of  head.  Pulse  and  temperature  rising.  No  paralysis.  Urine 
negative. 


118 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


119 


CASE  56. 


Female;    49;    married;    housework. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Vomited  blood  once,  several  years  ago.  Never  any 
gastric  symptoms  since. 

Pres.  III. — Three  months  ago  was  accidentally  struck  on  the  left 
breast  by  her  husband's  elbow.  Slight  pain  and  tenderness  fol- 
lowed. Within  a  few  days  she  discovered  a  "lump"  in  this  breast, 
which  has  gradually  increased  in  size.  In  other  respects  she  is  per- 
fectly well,  so  far  as  she  knows. 

Phys.  Exam. — Well  developed,  plump,  color  good.  Heart,  lungs, 
and  abdomen  negative.  Urine  normal.  Bowels  regular.  Left 
breast  not  enlarged,  tender,  nor  inflamed.  In  upper  inner  quadrant 
is  a  hard  mass,  irregularly  ovoid  in  shape,  not  tender  nor  painful, 
not  adherent  to  skin  or  subjacent  muscle.  This  mass  is  larger  than 
the  average  English  walnut  and  is  flattened.  Nipple  normal  in  size, 
shape,  and  color,  and  not  retracted.  She  has  not  lost  flesh.  No 
glands  in  the  axilla,  so  far  as  can  be  discovered  by  touch. 


T20 


Diagnosis  ?  Prognosis  ?  Treatment 


CASE  57. 


Male;   20;   single;  teamster. 

Fam.  Hist. — Not  important. 

Prev.  Hist. — Typhoid  at  20.  Cramps  in  abdomen;  have  been  a 
common  occurrence  for  ten  years,  sometimes  with  vomiting.  No 
pain  after  meals;  distress  does  not  seem  to  be  associated  with  food. 
General  health  good. 

Pres.  III. — Five  days  ago  sharp  attack  of  cramps,  much  like  pre- 
vious attack.  Subsided  as  usual,  but  left  considerable  pain  in  right 
hip  which  has  continued.  No  headache;  no  vomiting;  no  chills. 
Pain  somewhat  increased  with  movements  of  right  thigh. 

Phys.  Exam. — Well  developed  and  nourished.  Pupils  equal  and 
react.  Tongue  moist,  slight  white  coat.  Pulse  80,  good  volume 
and  tension.  Temperature  normal.  Heart  and  lungs  negative. 
Abdomen  slightly  tender  throughout,  more  so  in  the  right  lower 
quadrant,  with  pain  which  is  referred  to  the  right  anterior  superior 
spine  and  extending  down  the  right  thigh.  Slight  tenderness  in 
right  groin.  No  fullness;  no  mass  in  abdomen.  Four  days  later 
tenderness  persisted,  also  pain.  Laparotomy  showed  inflam- 
mation of  the  appendix  with  a  very  small  amount  of  pus  in  an  ap- 
parently well  walled-off  cavity,  deep  in  the  pelvis,  below  and  behind 
cecum.  Appendix  removed.  Drainage.  Ten  days  later  slight 
discharge  from  sinus.  Wound  granulating.  Patient  still  complained 
of  even  more  severe  pain  in  the  right  hip  and  groin,  and  now  has 
tenderness  in  right  groin  extending  down  thigh  to  a  point  eight  inches 
below  Poupart's  ligament.  Slight  swelling  of  upper  half  of  right 
thigh;  very  slight  fullness  in  groin;  no  fluctuation.  Ten  days  later 
increase  in  these  symptoms  with  marked  fullness  in  groin.  Con- 
siderable swelling  of  thigh  with  tenderness  and  a  deep  sense  of 
fluctuation  on  the  outer  side  of  right  thigh  extending  up  toward  groin. 
Patient  now  has  irregular  temperature,  reaching  1010  at  night; 
pulse,  about  100.  Has  lost  weight,  looks  sick,  as  if  suffering  from  some 
chronic  disease.  No  special  distressed  or  peritoneal  look;  sleeps 
well  after  mild  opiate. 


122 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


123 


CASE  58. 


Male;    42;    single;    provision  dealer. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Negative. 

Pres.  III. — Has  had  pain  referred  to  left  jaw  for  seven  days.  Re- 
cently a  swelling  has  appeared  at  site  of  pain,  which  he  also  feels 
in  floor  of  mouth.  % 

Phys.  Exam. — Well  developed  and  nourished.  Tongue  slightly 
coated.  Heart,  lungs,  abdomen,  and  urine  normal.  Knee-jerks 
present.  Fluctuating  swelling  over  and  below  ramus  of  left  lower 
jaw,  tender  and  reddened.  Also  a  sinus  in  left  side  of  floor  of  mouth, 
leading  down  to  roots  of  teeth,  which  may  be  felt  with  a  probe. 
Mouth  not  dry.     Leucocytes,  15,200. 


124 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


125 


CASE  59. 


Female;  18;  single;  Germany;  housework. 

Fain.  Hist. — Negative. 

Prev.  Hist. — Always  well.  Patient  confesses  to  having  spent  past 
thirty  days  in  a  house  of  questionable  character. 

Pres.  III. — Two  days  ago  fell  off  curbstone  and  twisted  her  ankle. 
Immediate  disability  which  lasted  only  a  few  minutes.  Next  day 
walked  as  usual.  That  night  went  to  a  dance,  walking  and  dancing 
without  pain.  Next  day  ankle  swollen,  considerable  pain.  Pro- 
fuse vaginal  discharge  for  past  two  weeks.     Pain  on  micturition. 

Phys.  Exam. — Well  developed  and  nourished.  Pupils  equal  and 
react.  Tongue  clean.  Pulse,  90;  temperature,  ioo°.  Heart  and 
lungs  negative.  Abdomen  negative.  Reflexes  normal.  Slight 
swelling  over  internal  malleolus  of  right  foot;  some  tenderness,  not 
sharply  localized  at  any  point.  Pain  on  motion.  Ecchymosis  con- 
siderable. No  signs  of  crepitus  or  abnormal  mobility  made  out. 
Four  days  later  swelling  diminished;  tenderness  slight;  plaster  cast. 
Four  days  later  patient  up;  very  little  pain  on  motion  of  ankle; 
slight  swelling  and  tenderness  remain.  Two  weeks  after  injur}' 
patient  again  in  bed.  Tenderness  and  slight  swelling  in  both  groins. 
Tenderness  in  both  iliac  fossae.  Temperature  again  averages 
ioo°;  pulse,  90.  Ankle  is  now  considerably  swollen,  very  tender  and 
painful.  Vaginal  examination  shows  tenderness  and  slight  indura- 
tion on  both  sides  of  cervix;  uterus  only  slightly  movable. 


126 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


127 


CASE  60. 

Male;  34;  married;  blacksmith. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Three  years  ago  attack  of  abdominal  pain  with 
nausea  and  vomiting,  tenderness,  constipation.  Diagnosis  of  attend- 
ing physician — appendicitis.     Recovered  quickly  without  operation. 

Pres.  III. — Four  days  ago  taken  with  cramps  in  abdomen. 
Went  to  bed.  Past  two  days  vomited  three  times.  No  chills. 
Pain  has  been  cramp-like,  seems  to  occupy  whole  of  abdomen.  No 
tenderness. 

Phys.  Exam. — Well  developed  and  nourished;  does  not  look  sick. 
Pupils  equal  and  react.  Tongue  moist,  clean.  Pulse  regular,  60; 
temperature,  98. 6°.  Heart  and  lungs  negative.  Abdomen :  no 
tenderness  or  spasm  to  speak  of.  Abdominal  pain  seems  to  be  re- 
lieved rather  than  increased  by  pressure  in  epigastric  region. 

Further  examination? 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


129 


CASE  61. 

Male;  22;  student;  New  Hampshire. 

Fam.  Hist. — Negative. 

Prev.  Hist. — As  a  child  had  mumps,  measles,  chicken-pox,  whoop- 
ing-cough, and  quinsy  sore  throat.  Six  years  ago,  after  pitching  hay 
in  the  daytime,  was  seized  about  midnight  with  sudden  pain  in  the 
lower  abdomen  which  "doubled  him  up."  He  vomited  and  had 
diarrhea.  His  abdomen  became  distended  and  was  extremely 
tender.  He  was  given  salts  but  no  food  for  four  days;  in  bed  three 
weeks.  The  pain  was  more  severe  in  the  right  lower  quadrant. 
Went  to  school  in  the  following  year,  but  did  not  take  exercise.  Nine 
months  after  came  a  second  similar  attack,  but  without  vomiting. 
He  was  in  bed  two  weeks. 

Pres.  III. — No  attacks  since,  but  says  if  he  exercises  violently 
he  has  slight  tenderness  in  the  right  side  which  passes  away  in  a  few 
hours.  This  worries  him.  Sleep,  appetite,  and  bowels  are  normal. 
He  never  feels  feverish  or  chilly;  no  variation  in  health  or  strength. 
Micturition  slightly  more  frequent  but  otherwise  normal.  He  now 
remembers  that  he  had  the  "yellow  jaundice"  when  fourteen  years 
old.     No  pain  at  that  time. 

Phys.  Exam. — Well  developed,  fairly  nourished,  thin.  Heart  and 
lungs  negative.  Abdomen  negative,  save  for  slight  tenderness  on 
deep  pressure  over  a  point  one-third  from  right  anterior  superior 
spine  of  ilium  toward  umbilicus.  After  running  a  mile  or  doing 
hard  physical  work,  he  feels  sore  at  this  spot.  Urine  high  colored, 
1020,  acid,  no  albumen;  temperature,  98. 6°;  pulse,  60.  No  leuco- 
cvtosis. 


130 


Diagnosis  ?  Prognosis  ?  Treatment  ? 

How  important  is  the  mental  element  in  this  case?  Would  you 
recommend  operation?  If  so,  when?  May  he  finish  six  weeks' 
college  work?     If  no  operation,  give  treatment  in  detail. 


CASE  62. 

Female;  28;  married;  housework;  Ireland. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Typhoid  at  19.  Three  miscarriages,  each  at  four 
months.  Hysterectomy  three  years  ago.  Patient  says  this  fol- 
lowed an  illness  of  three  months,  with  much  pain.  Since  operation 
patient  has  been  well,  except  for  habitual  constipation. 

Pres.  III. — Ten  days  ago  patient  was  taken  with  cramp-like  pain 
in  the  abdomen.  The  bowels  had  not  moved  for  five  days,  though 
patient  had  taken  salts  twice  during  that  time.  Headache  and  dull 
pain  in  the  abdomen  has  greatly  increased.  Eight  days  ago  slight 
movement  of  bowels.  Three  days  ago  another  slight  movement 
and  fainted  while  at  stool.  Appetite  poor  past  three  weeks.  Pain 
in  the  abdomen  more  severe  yesterday  and  to-day  than  at  any  other 
time.     Not  localized  in  any  particular  spot. 

Phys.  Exam. — Well  developed  and  nourished.  Pupils  normal. 
Tongue:  dirty  brown  coat.  Pulse  regular,  good  volume  and  ten- 
sion, 100;  temperature,  ioo°.  Heart  and  lungs  negative.  Abdo- 
men full  in  flanks.  No  fluid  wave.  Slight  general  tenderness,  a 
little  more  marked  in  right  iliac  region.  No  spasm.  Vaginal 
examination  negative.  Rectal  examination:  no  ballooning;  no 
feces  felt.  Extremities  negative.  Leucocytes,  8500.  Urine  nega- 
tive. 


132 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


*33 


CASE  63. 


Female;  20;  single;  waitress. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Denies  venereal.     No  previous  gastric  trouble. 

Pres.  III. — Sharp,  stabbing  pain  in  lower  abdomen  twenty  hours 
ago.  Vomited  several  times  since;  no  blood  in  vomitus.  No  chill. 
Catamenia  regular,  stopped  flowing  one  week  ago.     Bowels  regular. 

Phys.  Exam. — Conscious  and  in  pain.  Well  developed,  fairly 
nourished.  Pallid;  respiration  rapid  and  superficial;  restless. 
Pulse  150,  very  feeble.  Temperature,  990.  Heart  and  lungs  nega- 
tive. Urine  negative.  Abdomen  universally  tender,  slightly  rigid, 
and  moderately  and  uniformly  distended.  Moderate  voluntary  and 
involuntary  muscular  spasm  of  abdominal  parietes.  Tympanitic 
about  umbilicus;  dull  in  flanks.  Rectal  examination  shows  tender- 
ness high  up  on  right  side.  No  vaginal  examination  made  (patient 
unmarried).  High  enema  produced  good  result.  Patient  vomited 
brown  material  just  after  entrance.  No  vaginal  discharge.  No 
leucocyte  count  made. 


134 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


i35 


CASE  64. 


Male;   32;   married;   born  in  Russia;   shoe  dealer. 

Fam.  Hist. — Not  obtained. 

Prev.  Hist. — Never  sick  in  bed. 

Pres.  III. — Past  five  years  lump  size  of  fist  in  right  chest,  just  above 
nipple;  never  painful  or  tender;  not  increased  in  size  for  more  than 
three  years.  Yesterday,  while  standing  on  the  platform  of  a  train, 
suddenly  thrown  against  the  iron  railing,  striking  against  this  tumor, 
also  against  head;  unconscious  for  a  few  minutes;  recovered;  as- 
sisted to  a  seat;  later  walked  home.  Next  morning  no  head  symp- 
toms except  slight  dizziness.  Tumor  appeared  to  be  considerably 
larger.  Pain  in  this  region  considerable.  Patient  states  positively 
that  tumor  is  now  three  times  the*- size  it  was  before  the  injur}'. 
Coughs  occasionally. 

Phys.  Exam. — Well  developed  and  nourished.  Pupils  equal  and 
react.  Tongue:  white  coat.  Pulse,  80;  temperature  normal. 
Dullness  with  diminished  respiration  and  absent  fremitus  over  patch 
size  of  palm,  region  of  angle  left  scapula,  behind.  Right  lung  nor- 
mal. Abdomen  negative.  Knee-jerks  not  obtained.  Right  chest 
shows  tumor  mass  size  of  half  a  head  extending  from  right  nipple 
to  and  over  clavicle,  on  to  shoulder.  Soft  and  not  fluctuant.  Lower 
portion  firmer  than  upper  portion.  Skin  apparently  not  stretched  to 
any  great  extent.  Small  area  of  ecchymosis  size  of  palm  over  this 
tumor,  in  the  region  of  clavicle.  For  following  five  days  there  was 
no  change  in  physical  signs,  but  patient  complained  of  steady  and 
somewhat  increasing  pain,  which  he  said  was  sufficient  to  keep  him 
awake  at  night.     Urine  normal.     No  leucocytosis. 


136 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


i37 


CASE  65. 


Male;    23;    single;    salesman. 

Fam.  Hist. — Good. 

Prev.  Hist. — Negative. 

Pres.  III. — While  playing  baseball  was  struck  on  the  outer  side 
of  the  left  leg,  near  the  ankle,  by  a  batted  ball.  Severe  pain  followed 
by  numbness  resulted,  with  partial  disability.  He  continued,  how- 
ever, to  play  for  some  time.  Limped  home  with  a  cane.  Bathed 
foot  in  hot  water,  put  on  a  bandage,  and  moved  around  the  house 
for  two  days.  Did  not  feel  feverish.  Consulted  physician  on  the 
fourth  day. 

Phys.  Exam. — Well  developed  and  nourished.  Heart,  lungs, 
abdomen,  and  urine  normal.  Perfectly  well  except  for  left  leg  which 
is  slightly  swollen  in  lower  half;  tender  and  painful.  Surface  tem- 
perature slightly  increased.  Swelling  most  marked  over  lower  quarter 
of  fibula  and  below  it.  Ecchymosis  extends  from  one  inch  below 
fibula  halfway  up  outside  of  leg.  Tenderness  most  marked  and  acute 
one  inch  above  tip  of  external  malleolus.  No  crepitus;  no  deformity. 
Can  support  part  of  weight  on  left  foot,  but  only  with  considerable 
pain  referred  to  and  above  outer  ankle.  Gentle  antero-posterior 
motion  of  ankle-joint  not  painful;  lateral  motion  moderately  painful. 
Dorsalis  pedis  pulsates.  No  glands  in  groin.  Pulse,  80;  tempera- 
ture, 990.  Sleeps  fairly  well,  but  wakes  with  a  jump  if  leg  is  moved 
suddenly. 


138 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


139 


CASE  66. 

Male;  53;  married;  hackman. 

Fam.  Hist. — Negative. 

Prev.  Hist. — One  year  ago  "operation  on  knee,"  character  im- 
possible to  determine.  Gonorrhea  three  times,  last  attack  twenty 
years  ago.     Three  or  four  drinks  daily. 

Pres.  III. — Nine  days  ago  a  painful  pimple  appeared  on  back  of 
neck;  it  has  steadily  increased  in  size  and  in  pain  and  tenderness. 
General  malaise;  slight  fever;  neck  very  sore  and  stiff.  Says  he 
gets  up  once  to  "make  water"  at  night.  Drinks  as  much  as  "any 
other  man." 

Phys.  Exam. — Fairly  developed;  pale.  Heart  and  lungs  negative. 
Extremities,  including  knees,  apparently  normal  save  for  operation 
scar.  Constipated.  On  back  of  neck  from  middle  line  forward 
to  left  ear,  and  from  level  of  tip  of  ear  to  upper  edge  of  scapula,  is  a 
purplish  brawny  swelling,  indurated  and  peppered  with  numerous 
small  yellow  foci  of  pus  and  sloughs,  from  one  of  which  a  moderate 
quantity  of  sero-sanguino-purulent  liquid  escapes.  This  swelling 
is  hot  and  very  tender.  Pulse,  no;  temperature,  103. 50  and  rising. 
Urine  1038,  pale,  acid,  slight  trace  albumen,  1.84  %  sugar.  Acetone 
and  diacetic  acid  present. 


140 


Diagnosis  ?  Prognosis  ?  Treatment  ? 

Is   operation  indicated?     What   contraindications?     What   anes- 
thetic?    Details  of  operation?     Details  of  after-treatment? 


141 


CASE  67. 


Male;  61;  married;  laborer. 

Fam.  Hist. — Good. 

Prev.  Hist. — Always  healthy. 

Pres.  III. — Six  days  ago  was  well.  On  the  following  day  had  pain 
in  right  hand.  Does  not  remember  injuring  it  in  any  way.  Pain 
and  swelling  steadily  increased.  Has  had  chills.  Was  attended 
by  a  physician  who  sends  him  to  hospital  to-day. 

Phys.  Exam. — Well  developed,  fairly  nourished.  Looks  very 
sick.  Pulse  100,  regular,  rather  weak,  poor  tension;  temperature, 
1030  (afternoon).  Eyes,  heart,  and  lungs  normal.  Moderate 
arterio-sclerosis.  Respiration,  30.  Abdomen  negative.  Right  arm 
and  hand  swollen  to  twice  their  normal  size,  red  or  reddish  brown 
throughout.  Very  tender  and  painful.  Fluctuation  in  forearm 
and  over  olecranon.  Upper  arm,  wrist,  and  hand  indurated. 
Numerous  bluish -brown  blebs;  radial  pulse  may  be  detected.  Skin 
universally  tense.  No  glands  in  axilla  or  at  elbow.  18,000  leuco- 
cytes.    Urine  1010,  acid,  high  color,  slight  trace  albumen. 


142 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


143 


CASE  68. 

Male;   22;   single;   wood  chopper;   Polish. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Negative.     Denies  venereal.     Habits  good. 

Pres.  III. — Nine  weeks  ago  was  struck  on  right  thigh  by  falling 
tree.  He  managed  to  reach  a  house  two  miles  distant  without  as- 
sistance. Was  taken  to  a  "hospital"  and  for  eight  weeks  remained 
in  bed.  Patient  talks  only  patois,  and  no  further  details  can  be 
obtained. 

Phys.  Exam. — Very  well  developed  and  nourished.  Pulse  and 
temperature  normal.  Heart,  lungs,  abdomen,  and  urine  negative. 
Cannot  stand  on  right  leg.  Right  thigh:  marked  outward  deform- 
ity at  middle  bone  much  thickened;  no  crepitus  nor  tenderness; 
no  inflammation;  entire  thigh  apparently  involved.  Right  leg 
one  and  three-quarter  inches  shorter  than  left.  Moderate  tenderness 
at  site  of  tumor.     Leucocytes,  8200. 


144 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


i°  145 


CASE  69. 

Male;  26;  married;  laborer. 

Fam.  Hist. — Negative. 

Prev.  Hist.— Children's  diseases.  No  previous  head  injury. 
Habits  moderately  alcoholic. 

Pres.  III. — Said  to  have  fallen  in  the  street  several  hours  ago. 
Brought  to  hospital  in  police  ambulance. 

Phys.  Exam. — Semiconscious.  Can  be  roused  by  supra-orbital 
pressure;  when  roused,  answers  incoherently.  Does  not  know  what 
happened  to  him.  Strong  odor  of  alcohol  on  breath;  has  evidently 
vomited.  No  bleeding  from  nose,  mouth,  or  ears  at  present.  Pupils 
small  and  unequal,  left  being  smaller;  they  react  sluggishly  to  light. 
Moves  limbs;  apparently  no  paralysis.  No  fractures  of  trunk  or 
extremities.  On  left  parietal  eminence  a  contusion  and  abrasion 
with  considerable  swelling  and  infiltration;  no  obvious  depression 
of  bone.  Pulse,  100;  temperature,  97.60.  No  leucocytosis.  Urine 
negative. 


146 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


147 


CASE  70. 


Female;  24;  single;  housework. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Was  in  hospital  three  months  ago  for  "tumor  of 
knee";    was  operated.     Never  jaundiced. 

Pres.  III. — One  week  ago  severe  pain  in  right  side  of  abdomen, 
becoming  general;  no  vomiting.  Pain  has  diminished.  Bowels 
constipated ;  has  been  in  bed  four  days  ;  no  chill.  Catamenia 
regular. 

Phys.  Exam. — Poorly  developed  and  nourished;  pallid.  Pupils 
normal;  slight  internal  strabismus.  Lips  dry  and  partly  covered 
with  sordes.  Tongue  coated  and  dry.  Pulse  100,  regular,  fair 
strength;  temperature,  100.20.  Heart  and  lungs  negative.  Leuco- 
cytosis,  15,000.  Reflexes  normal.  Abdomen  slightly  distended 
and  tender,  latter  more  marked  on  right  side.  Slight  muscular 
spasm  most  marked  on  right.  No  definite  tumor  felt.  Rectal 
examination  shows  large  fecal  mass.  Vaginal  examinations  negative 
except  for  slight  tenderness  in  right  vaginal  vault. 


148 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


149 


CASE  71. 


Male;  66;  married;  carpenter. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Always  well.  Three  years  ago  examination  of  urine 
showed  "slight"  amount  of  sugar.  Lived  on  mildly  restricted  diet 
since. 

Pres.  III. — One  year  ago  horse  stepped  on  left  foot.  Small  lacer- 
ated wound  which  healed.  In  a  few  weeks  pain  returned;  grad- 
ually increased  in  severity  ever  since.  Three  months  ago  noticed 
small  black  spot  outer  side  great  toe.  At  this  time  two  and  a  half 
per  cent,  of  sugar  in  urine.  Diabetic  diet  and  increasing  doses  of 
codein  up  to  five  grains  three  times  a  day  do  not  decrease  sugar  nor 
relieve  pain.  Gangrenous  area  did,  however,  slightly  decrease  and 
become  dry  and  covered  with  a  crust.  Not  much  increase  in  amount 
of  urine.  Frequency  of  micturition.  No  special  thirst.  Appetite 
good;  has  lost  twenty-five  pounds  in  past  year.  Past  [week  gan- 
grenous area  appears  to  be  slowly  increasing.     Pain  severe. 

Phys.  Exam. — Well  developed  and  nourished.  Pupils  equal, 
react.  Tongue  moist;  slight  white  coat.  Pulse  regular;  slight 
arteriosclerosis;  rate  90.  Heart  negative.  Lungs:  resonance  good, 
harsh  respiration  at  right  apex;  no  rales.  Abdomen  negative. 
Knee-jerks  not  obtained.  Gangrenous  area  on  great  toe  size  of 
a  half-dollar.     Sugar,  two  and  a  half  per  cent.     No  acetone. 


150 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


151 


CASE  72. 


Male;  4S;  single;  steward. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Has  been  subject  to  occasional  attacks  of  indigestion. 
Latterly  a  moderate  amount  of  alcohol. 

Pres.  III. — For  a  week  or  two  has  had  indigestion.  Attack  of  pain 
came  on  about  10  a.m.;  severe  general  abdominal  cramp,  more  in 
upper  than  in  lower  part;  severe  enough  to  absolutely  disable  him 
and  extremely  sudden.     Came  to  hospital  that  day,  pain  then  abating. 

Phys.  Exam. — Abdomen  uniformly  distended  and  tender;  tym- 
panitic. No  tumor.  Enema  resulted  in  fair  movement  and  much 
decrease  of  distention.  Temperature  about  ioo°.  Leucocytes, 
14,000.  Was  seen  next  day;  then  not  distended,  but  tender  over 
eighth  left  costal  cartilage,  and  just  below  it,  more  especially  just  below 
the  tip  of  the  eighth  costal  cartilage,  left  side.  Some  little  spasm. 
Gall-bladder  region  free;  appendix  free.  Nothing  palpable  any- 
where. Percussion  showed  small  stomach;  liver  not  abnormal; 
spleen  not  discoverable.  No  jaundice.  Yesterday's  urine  1040, 
marked  sugar;  to-day's  1030,  no  sugar;  examination  otherwise 
negative.  Next  day  trace  of  bile  in  urine,  1029,  no  sugar.  Ab- 
dominal conditions  better.  Tenderness  more  nearly  at  level  of 
umbilicus.  Little  pain,  spasm  less.  At  about  three  days  seemed 
nearly  well,  though  still  some  soreness.  Then  temperature  went  up 
again — irregular  temperature;  reached  maximum  of  1030;  pulse 
not  correspondingly  light.  No  increase  of  pain.  Leucocytes, 
8000  to  13,000  throughout.     No  sugar  at  any  time  since  the  first. 


152 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


*53 


CASE  73. 

Male;  37;  married;  barber. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Negative. 

Pres.  III. — Right  inguinal  hernia  for  ten  years;  in  scrotum  for 
past  five  years.  Occasionally  has  some  difficulty  in  reduction. 
Never  strangulated.  Business  requires  him  to  stand  up,  which  for 
past  few  months  has  caused  him  considerable  pain.     Constipated. 

Phys.  Exam. — Well  developed  and  nourished.  Pupils  equal  and 
react.  Tongue  clean.  Heart  area,  sounds,  and  action  normal. 
Lungs  negative.  Abdomen  negative  except  for  left  inguinal  ring, 
which  admits  two  fingers.  Pulsation  on  cough.  When  patient  is 
erect  a  mass  the  size  of  an  incandescent  light  globe  appears  in  scro- 
tum. Operation;  radical  cure,  Bassini.  Perfectly  normal  con- 
valescence for  two  weeks  with  first  intention  wound.  At  this  time, 
following  attempt  to  move  the  bowels,  patient  had  fainting  spell  and 
was  found  with  rapid  respiration,  rapid  pulse,  some  dyspnea,  and 
slight  cyanosis.  Symptoms  gone  in  about  an  hour.  Enema  moved 
bowels  freely;  patient  perfectly  comfortable.  Next  day  patient 
felt  perfectly  well,  anxious  to  get  up.  At  noontime  had  a  second  and 
very  sudden  onset  of  dyspnea  with  marked  cyanosis  and  rapid 
respiration,  weak  and  rapid  pulse,  cold  perspiration.  Foot  of  bed 
elevated.  Shock  enema.  Subcutaneous  stimulation.  Bowels  moved 
freely  as  result  of  shock  enema.  Slight  improvement  in  symptoms 
during  next  hour.  Pulse  returned  to  wrist,  rate  120.  Next  four 
hours  slight  cyanosis  and  rapid  respiration  persisted,  but  patient 
appeared  to  be  fairly  comfortable.  Pulse  regular  and  rapid.  At 
this  time  cyanosis  and  dyspnea  suddenly  appeared;  pulse  again 
left  the  wrist.  Heart  again  became  rapid  and  irregular.  Examina- 
tion of  heart  (before  negative)  now  showed  slight  enlargement  to 
the  right,  downward,  apex  being  in  the  sixth  space,  where  before 
it  had  been  in  the  fifth.  Diminished  respiration  and  moist  rales 
right  axilla  and  back. 


J54 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


i55 


CASE  74. 


Male;  25;  single;  painter. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Negative. 

Pres.  III. — Fell  from  roof  of  Adams  Square  Subway  Building, 
striking  his  head.  Brought  into  Relief  Station  semiconscious,  with 
a  pulse  of  high  rate  and  poor  quality,  very  irregular.  Wound  at 
left  vertex,  with  a  linear  fracture  of  the  skull,  running  transversely. 
This  was  cleaned  and  dressed.  After  about  an  hour  there  began 
to  be  blackening  of  the  left  eye.  Was  seen  about  two  hours  after 
the  accident. 

Phys.  Exam. — He  was  dull,  semiconscious,  rational,  lying  quiet, 
without  spasm.  Temperature,  990;  pulse  80,  fair  quality,  not  char- 
acteristic— now  not  irregular.  No  paralysis  of  limbs.  Reflexes 
normal.  Left  orbit  swollen  and  blackened,  with  much  sub-con- 
junctival  hemorrhage.  No  hematoma  about  bridge  of  nose  on  right 
eye.  As  he  lay  quiet  there  was  marked  divergence  of  the  left  eye 
out  and  up;  this  lessened  somewhat  as  he  was  roused.  The  pupil 
reacted  to  light,  but  was  much  smaller  than  on  the  right.  The  right 
pupil  larger  than  pupils  average.  No  bleeding  from  ears;  some 
bleeding  from  nose.     Urine  negative. 


156 


Diagnosis  ?  Prognosis  ?  Treatment  ? 


i57 


CASE  75. 


Female;   39;  married;   Canada;  housewife. 

Fam.  Hist. — Negative. 

Prev.  Hist. — Typhoid  fever  eighteen  years  ago.  Eight  children, 
no  miscarriages. 

Pres.  III. — Patient  states  that  about  three  weeks  ago  began  to 
have  throbbing  pain  in  fourth  finger  of  her  left  hand,  with  some 
swelling,  redness,  and  tenderness.  No  knowledge  of  injury.  One 
week  later  finger  was  opened  by  physician.  Two  weeks  after  onset, 
second  incision.  Process  now  involved  whole  hand.  Later  more 
and  free  incisions  of  finger.     Daily  dressings. 

Phys.  Exam. — Well  developed  and  nourished.  Rather  pale. 
Pupils  react;  right  larger  than  left.  Patient  says  it  has  been  so  for 
years.  Tongue  dry.  Pulse  regular,  good  volume  and  tension,  105. 
Slight  arteriosclerosis.  Heart  and  lungs  negative.  Abdomen  nega- 
tive. Spleen  just  felt.  Extremities  negative,  except  left  hand 
which  shows  open  sinus  extending  whole  length  of  fourth  finger; 
necrotic  material;  bone  exposed.  Swelling  and  redness  of  palm 
and  dorsum.  Daily  dressings;  soaks.  Doses  of  strychnia.  Four 
days  later  removal  of  two  distal  phalanges,  flaps  not  united.  Twenty- 
four  hours  later  patient  had  considerable  hemorrhage  in  the  dressing. 
These  hemorrhages  recurred  at  intervals  of  from  twelve  to  twenty- 
four  hours  for  a  week,  sometimes  following  dressing;  sometimes 
occurring  several  hours  after  being  dressed  and  bandaged.  Septic 
processes  meanwhile  improved  rapidly.  Blood  examinations  made 
at  this  time  showed  hemoglobin  25  per  cent.;  red  corpuscles,  250,- 
000,000;  white  corpuscles,  135,000.  Differential  count:  poly- 
morphonuclear neutrophiles,  69  per  cent.;  small  mononuclears,  5 
per  cent.;  large  mononuclears,  7  per  cent.;  mast  cells,  4  per  cent.; 
myelocytes,  14.7  per  cent.;  rarely  any  eosinophils;  some  variation 
in  size  of  reds.  Tendency  to  paleness;  moderate  polychromato- 
philia.  Spleen  now  increased  in  size  until  it  extended  a  hand's 
breadth  below  costal  margin. 


i*8 


Diagnosis?  Prognosis?  Treatment? 


i59 


Case  teachings  s'ur„e 

ummi 


